Karen Quero, SN
It took me 9 hours to complete this case study.
Pediatric Gastroenteritis
SKINNY Reasoning : Harper Anderson, 5 months
... [Show More] old
1
Primary Concept
Infection
Interrelated Concepts In order of emphasis
Inflammation
• Perfusion
Fluid and Electrolyte Balance
Acid-Base Balance Clinical
Judgment
NCLEX Client Need Categories Percentage of Items from Each Cate o
/Subcategory
Covered in Case Study
Safe and Effective Care Environment
• Management of Care 17-23%
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
• Basic Care and Comfort 6-12%
Pharmacological and Parenteral Thera les 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%SKINNY Reasoning
Part 1: Recognizing RELEVANT Clinical Data
Patient Care Begins:
History of Present Problem:
Harper Anderson is a 5-month-old female who was brought into the physician's office for diarrhea and vomiting over the
past two days. She had two loose 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 more sleepy today. She is unable to keep any feedings down today. She has had
four loose, watery stools and emesis x3 this morning. She has not had a wet diaper since yesterday evening. She is 25
inches (63.5 cm) in length and weighs 14 pounds, 2 ounces (6.4 kg). She weighed 15 pounds, 2 ounces (6.86 kg) at her
Last office visit two weeks ago. Harper is a direct admit to the pediatric unit where you are the nurse responsible for her.
Personal/Social History:
Harper's mother Nicole is 21 years old. She is a single mother and this is her first child. Nicole is not currently working
und lives with her parents. Though she has strong social support from her parents, she feels constantly overwhelmed as a
new mother.
Past Medical History (PMH):
● Healthy full-term infant that weighed 6 pounds 10 ounces (3.0 kg) at birth. No current health problems. Mom is
no longer breast feeding and Harper is on formula.
● Mother had no complications with pregnancy.
● Has not had any immunizations from birth, including rotavirus
2
RELEVANT Data from Present Problem: Clinical Significance:
1. She has had diarrhea and vomiting over
the past two days.
2. She has had four loose and watery
stools. She has vomited 3 times in the
morning.
3. She is less active, lethargic, and
uninterested in play. Unable to keep
feedings down.
4. Has not had a wet diaper since
yesterday in the evening.
5. She currently weighs 14 lbs. and 2 oz.
She has previously weighed 15 lbs. and 2
oz two weeks ago.
1 & 2. By vomiting and having loose stools over the course of two days,
that is a short amount of time. Such a short amount of time can alter her
hydration and electrolyte balance. Having loose stools removes the body
from fluid which is being excreted. By vomiting 3 times, Harper is
diminishing her potassium (3.5-5), sodium (135-145), and chloride levels
(99-109). Her body is removing electrolytes without replenishing which
will cause her body to become lethargic and could potentially create
cardiac issues like dysthymias.
3. Her becoming lethargic, less active, and uninterested in playing is
concerning because it can alter her level of consciousness. An altered
level of consciousness can result from decreased electrolytes like sodium
or potassium. Due to Harper vomiting 3 times a day, she is becoming
dehydrated and unable to keep food down which can explain her lethargy
since she has no energy after expelling.
4. Not obtaining a wet diaper indicates decreased urine output. A
decreased urine output signifies an increase in dehydration. The kidneys
are not receiving an adequate supply of nutrients and water which limit
the production of urine within the kidneys. Kidney labs should be
assessed to note functionality and filtration.
5. This weight fluctuation is abnormal. For every 1 lb. a child loses, it is
significant in the loss of hydration of a child. Losing a pound within 2
weeks is about 7% of the child’s weight. This finding is abnormal and
could be due to dehydration since the child has been vomiting and has
had frequent loose stools.
RELEVANT Data from Social History Clinical Significance:Patient Care Begins:
FLACC Behavioral Pain Scale
3
1. Her mother is 21 years old and Harper
is her first child.
2. Harper’s mother is unemployed. She
also lives with her parents. She is
constantly feeling overwhelmed with
motherhood.
3. Harper has not been immunized since
she was born.
1. Harper’s mother being young and having her first child can be a
lot to process and overwhelming due to not having a partner.
Being so young, there are many aspects of motherhood that are
difficult and she may be suffering from lack of knowledge when
taking care of her child. She may be unaware of how to help her
child with her vomiting and diarrhea episodes.
2. Being constantly overwhelmed is very stressful. She may not
know how to cope with her daughter’s medical issues and may
need support from her family and other resources to best aid her
daughter’s future diagnosis. Some resources include support
groups in the community, therapy, or parenting classes to better
take care of her child.
3. Harper not being immunized creates a problem because younger
children are more susceptible to bacteria and viruses. Having not
been immunized, the child’s defense and immunity is not matured
so she is more at risk of developing an illness or infection.
Education on immunization should be discussed with the mother
as immunizations can prevent further infection and protection for
future health as Harper keeps developing and coming in contact
with other children and pathogens.
Current VS: Pain Assessment- FLACC Behavioral Pain Scale
T: 102.2 F/39.O C axillary ) [96.8] Face: 1
p: 158 [80-150] Legs : 0
R: 38 [30] Activity: 1
BP: 62/42 [95/58] Cry: 1
02 sat: 95% RA Consolability: 2/ Tota1 score: 5/10
o 1 2
Face Relaxed or smile Occasional grimace, frown,
withdrawn
Frequent frown, clenched jaw, quivering chin
Legs Relaxed Uneasy , restless, tense Kicking or legs drawn up
Activity Lying quietly,
moves easily
Squirming, tense Arched, rigid, or jerking
Cry No cry (awake or
asleep
Moans, whimpers. Occasional
complaints
Crying, sobs, screams, frequent complaints
Consolability Content or
relaxed
Easy to console, distractible Difficult to console or comfort
Each of the five categories is scored from 0-2, resulting in a total of 0-10What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
4
RELEVANT VS Data: Clinical Significance:
1. High temperature of 102.2
2. High pulse rate of 158 bpm
3. High respiration rate of 38
4. Low blood pressure of 62/42
5. FLACC score of 5/10
1. The normal temperature for a child is 96.8. Harper has a high
temperature of 102.2 F, indicating that she is febrile. This means that her
body is actively fighting off either a bacterial or viral infection. Her body
temperature is increased due to her immune system responding to a
pathogen through an inflammatory response. To confirm an infection,
laboratory tests such as WBC count should be assessed.
2. The normal pulse rate is 80-150 bpm. Her HR is tachycardic at 158
bpm. This rapid HR can indicate body compensation. Her body is
compensating due to either being febrile, her body fighting off an
infection, or being dehydrated. She has had vomiting and diarrhea spells
which could have diminished her fluid level within her body. If fluid is
diminished, her blood volume could be decreased which could be
manifested by the elevated HR. Because of this, the HR compensates by
beating faster to provide the circulatory system with nutrients and to help
increase fluid volume for dehydration.
3. Normal respiration rate is around 30. She is tachypneic at 39 breaths
per min. This elevated level can be a result of her body compensating like
her heart rate. Breathing faster decreases her oxygen which can be seen as
her O2 saturation is at 95%. While it is not an abnormal finding, it should
be monitored so it does not decrease below 94%.
4. Normal blood pressure for this child is around 95/58. This hypotensive
finding is abnormal. Low blood pressure can be related to increased heart
rate. In addition, her blood pressure can be an indication of decreased
fluid volume in her body. A low fluid volume in the body is an indicator
for dehydration which can be seen through the lack of wet diapers,
vomiting and diarrhea, and weight loss of the child. Fluid should be
replaced in order to increase blood pressure. Fluid replacement should be
calculated according to weight which will be indicated under medical
orders.
5. A FLACC score of 5/10 indicates the child is in moderate pain. The
child is in discomfort due to not being able to be consoled, frowning,
tense, occasional complaints of the child based on the scale. To decrease
pain and discomfort the patient should be comforted to provide some
relief to the pain and discomfort felt. Some ways of decreasing pain and
discomfort is utilization of Sweet-ease, distraction therapy, music,
peek-a-boo, and soothing voice tones. Her mother can also hold her to
provide additional comfort.
Current Assessment:
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 3—4 seconds in both hands, brachial
pulses palpable bilaterally
NEURO: Lethargic, does not maintain eye contact with mom or caregiver
Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness
to palpation
GU: 5 mL dark amber, cloud urine noted in urine collection bag-sent to labWhat assessment data are RELEVANT that must be recognized as clinically significant by the nurse?
5
SKIN: Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no
shiny saliva present, when skin over Abd. is pinched, remains tented for 2—3
seconds
RELEVANT Assessment data Clinical Significance:
1. Irritable when awake, lethargic,
when crying no tears are present
2. Skin is pale, cool to the touch, and
capillary refill delayed 3-4 seconds
3. Lethargic and does not maintain
eye contact with mom
4. Abdomen is hyperactive and
absence of tenderness when palpated
5. Urine is dark amber, only 5 mL,
and cloudy
6. Anterior fontanel depressed, eyes
sunken, lips and tongue dry, no saliva
present, skin tenting for 2-3 seconds
1. The patient has a decreased LOC. She is lethargic, irritable, and
produces no tears. This indicates that the child is dehydrated. Lack
of production of tears shows that the child cannot produce fluid
due to not having enough fluid volume within her body. Being
lethargic and irritable could be a sign of electrolyte imbalance due
to her diarrhea and vomiting. Her balance of electrolytes like
potassium and sodium could be decreased. If the child is
hypokalemic, potassium should be elevated quickly to prevent
cardiac dysrhythmias. If the child has hyponatremia, it can could
cause lethargy.
2. Her skin is pale, cool, and has a delayed capillary refill. These
are all signs of a decreased blood volume circulating to the
extremities. Because her blood volume is diminished in her
extremities, this could mean that her body is going into shock due
to her high HR and respiration rate. If her body is in shock, her
blood would be shunted, which would explain the diminished
capillary refill, coolness, and pallor in the distal extremities.
3. Lethargy and lack of eye contact with her loved one is a
concerning sign of dehydration. This is due to a decreased LOC
which is seen as the child will not make eye contact with her
mother. Eye contact is sign of a healthy child since it would
indicate growth and development. However, because the child will
not make eye contact and is fatigued, the child’s body is severely
fighting off dehydration or decreased fluid volume.
4. Hyperactivity of the abdomen is an abnormal finding because it
signifies increased gastrointestinal activity. The child is 5 months
and should have seen started eating minimal solid foods only
recently. It is abnormal for the child to be hyperactive as food has
barely been introduced. An absence of tenderness upon palpation is
also abnormal since GI activity is elevated. Tenderness when
palpated is typically a sign of a gastrointestinal issue with a short
onset. However because no tenderness is felt, it can indicate a more
serious problem for the child as a long-term medical issue at this
age is serious and could lead to more detrimental issues.
5. Urine being dark amber and cloudy is abnormal. This can
indicate an infection within the urinary system as cloudiness
indicates white blood cells being detected within the urine. 5 mL of
urine is extremely little as the child should be producing about 1-3
mL per hour. A decrease in urine can indicate a functional issue
with the kidneys as the organs are not producing enough urine.
Dark amber color indicates there is a high concentration but lack of
output.
6. A depressed anterior fontanel is a major sign of dehydration in
children. Sunken eyes, dry mucus membranes and no saliva
indicate the child has a low fluid volume circulating within the
body and very dehydrated. Because there is a low fluid volume, the
child could be dehydrated as seen through other systems. SkinDiagnostic Results:
6
tenting is another abnormal finding as skin should recoil in less
than 2 seconds. All of these skin findings indicate the child is
experiencing dehydration or extremely low fluid volume within her
body.
What data must be interpreted as clinically significant by the nurse? (Reduction o Risk Potential/Physiologic Adaptation
RELEVANT
Diagnostic Data:
Clinical Significance:
*all normal values can be found underneath values*
TREND:
1mprove/Worsen
ing (Stable:
High Sodium level of 151 A high sodium level indicates a high concentration of sodium
within the body. This signifies that there is a diminished
amount of fluid level. The patient has been losing fluid with
the frequent episodes of diarrhea and vomiting. Because
sodium and water follow each other, sodium is in excess
since there is a lack of volume inside the child. There is a
higher concentration which is manifested by lethargy, sunken
eyes, and a depressed fontanel.
Worsening
Low Potassium of 3.1 A low potassium level of less than 3.5 is a serious abnormal
finding. This low level is resulted from the child’s diarrhea
and constant vomiting. As the child is constantly expelling
electrolytes, she is depleting her potassium level. A low
potassium can cause cardiac issues such a dysrhythmias. This
level is extremely important to raise immediately because the
child could develop cardiac rhythm changes which could
potentially become a life threat.
Worsening
Low Chloride of 92 A low chloride level is an indicator of diminished electrolytes
balance. Low chloride within the body is caused by the
Worsening
Basic Metabolic Panel (BMP)
Na K Cl C02 Gluc, Creat.
Current: 151 3.1 92 15 102 1.4
Most Recent: 138 3.8 101 22 105 0.6
Range: (135-145) (3.5-5) (99-109) (27-40) (60-100
)
(0.2-0.4)
Complete Blood Count (CBC)
WBC HGB PLTs % Neuts
Current: 19.8 15.2 225 88
Most Recent: 12.5 13.5 221 54
Range: (4.5-13.5) (11.5-15.5) (150-400) (54-62)
UA urine
analysis
Color Clarity Sp. Gr Protei
n
Nitrit
e
LET RBCs WBC
s
Bacteria Epitheli
al
Current: Yello
w
Cloud
y
1.033 Neg Pos Pos 2 > 100 Few Few
Range: ClearYello
w
Clear 1.016
-1.02
2
neg absent neg <1 or 2 <1-2 Few Few7
patient’s constant vomiting. When the body forcefully expels
contents from the stomach, all gastric contents like acids
leave the body. Chloride can be within the GI system, which
is lowered when the patient is constantly expelling the
contents of the GI system. Because chloride is an essential
nutrient to the body, it is manifested by the child’s lethargy
and decreased LOC.
Low CO2 level of 15 A low CO2 level is typically due to a decrease in acid/base
balance within the body. CO2 regulates the acid/base balance
within the body from preventing acidosis and alkalosis. A
decreased level from the GI system is due to the patient’s
constant loose stools. CO2 is being removed which alters the
patient’s acid/base balance. This can be manifested through
lethargy and the child’s irritability since electrolyte and
acid/base balance are shifted.
Worsening
Slightly high glucose of 102 While the glucose is only slightly elevated than the normal
range, it is important to note due to the symptoms that can
arise from an abnormal level. Glucose is one of the most
important nutrients in the body because every cell within the
body needs glucose (ATP) to function and for energy. An
abnormal glucose level could create an altered level of
consciousness and lethargy. However, because the level is
not of significance due to being 2 units elevated, the child’s
fatigue and LOC are produced from another finding.
Stable
High Creatinine of 1.4 High creatinine of 1.4 is extremely elevated. This can result
from dysfunctional kidneys as a result of decreased fluid
volume circulating through the organs. A high creatinine
level indicates that the kidneys are not being perfused
adequately and can be seen through the decreased urine
output of 5 mL that the child is producing. Because the
creatinine level is so high, it is a sign of dehydration and
diminished fluid volume within the body.
Worsening
High WBCs of 19.8 in blood Increased level of WBCs can indicate many issues within the
body. High white blood cells can mean that there is an active
infection within the body and the body is fighting against it
through an inflammatory response. WBC are the cells that
actively migrate to the site of infection to help protect the
body from the foreign pathogens.
Worsening
High Neutrophils of 88 Percentage of neutrophils is the percentage of white blood
cells. This lab level indicates an infection in the body or an
inflammatory response to a pathogen within the urine.
Neutrophils are the most common leukocyte to fight off an
infection. A high level means that there is a bacterial or viral
infection that the neutrophils are attempting to fight off.
Because it is seeming to be an infection in the GU system, a
decreased of urine output is common amongst the common
side effects of an infection.
Worsening
Yellow and cloudy urine The normal color of urine is clear to pale yellow which
indicates regular hydration status per medical order and
weight. Yellow and dark amber color in urine mean a lack of
fluid passing through the kidneys. This is common in
dehydration since the body is not being supplied with enough
No other results
are available to
compare and
determine a
trend.Part 11: Put it All Together to THINK Like a Nurse!
8
fluids to filter the urine and create more output. Normal urine
is free of sediment due to the kidneys actively filtering the
urine through the glomerulus. However, because the kidneys
are malfunctioning due to the lack of fluid volume, sediment
is not being excreted adequately. Cloudy urine could be a
result of white blood cells being dumped into the urine
because of an active infection. Other signs and symptoms of
an active GU infection is limited output and malfunction
kidneys seen through creatinine results.
High Specific gravity of
1.033
A high specific gravity indicates that the urine obtains a high
concentration. This can signify dehydration in the patient due
to the lack of fluid readily available to dilute the urine upon
excretion from the kidneys. A high specific gravity, cloudy
urine, and high WBC count are signs of dehydration or
infection within the urinary system.
Positive Nitrate in urine Nitrates found within the urine indicate that the urine
contains bacteria. The type of bacteria that creates a positive
level are gram-negative bacteria. Because this level
determines gram-negative bacteria, it also allows the
determination of E.coli within the urinary system since it is
the most common type of gram-negative bacteria. This test
along with high specific gravity, yellow and cloudy urine
provide indication that the patient obtains a positive urinary
infection.
High WBCs of >100 in urine A high level of WBCs within the urine means that there is an
active infection within the urinary system. An infection or
infectious pathogen can cause damage to the glomerulus
within the kidney. Because acute injury occurs, the
glomerulus cannot filter out adequately. As a result, white
blood cells are dumped into the urine due to the increase in
cells fighting against the infectious pathogens. An infection
could be suspected due to the cloudiness of the urine in
addition to the white blood cells count within the urine.
Positive LET A positive LET level provides information that an enzyme
from the WBCs is present within the urine. It may be evident
that an infection is present due to the increased number that is
being passed through the acutely damaged kidneys. A
dumping of WBCs, WBC enzymes, and positive nitrate
within the body can be resulted from an infectious pathogen
or from the lack of fluid flushing the bacteria within the
urinary system.
Few bacteria and epithelial
cells
Few bacteria and epithelial cells alone do not provide enough
indication of an active infection due to normal bacteria and
epithelial cells. However, because other urine components
have resulted in positive or high in number, the few bacteria
and epithelial cells provide indication that there is an
infectious pathogen present within the urinary system due to
fluid volume deficit or infection.1. After interpreting relevant clinical data, what is the primary problem?
Management of Care/Physiologic Adaptation)
Collaborative Care: Medical Management
2. State the rationale and expected outcomes or the medical plan of care. (Pharm. and Parenteral
Therapies)
9
Problem: PATHOPHYSIOLOGY IN OWN WORDS:
1. Gastroenteritis
2. Urinary tract infection (UTI)
1. Harper’s clinical manifestations and laboratory tests
indicate Gastroenteritis. Gastroenteritis is caused by an
infectious microorganism that inflames the intestinal tract
and stomach lining. The infectious pathogens that reside
within the GI tract release toxins that irritate the intestines
and linings. Electrolyte receptors that are found within the
GI tract are overwhelmed by the toxins. This impedes
reabsorption of fluid and electrolytes within the GI tract
which decreases overall fluid volume status. This is
significant within a child because the majority of a child’s
weight is based on fluid balance. Severity of the fluid and
electrolyte imbalance depends on the amount of fluid that is
lost in reabsorption. Harper’s dehydration is severe as a
result of her clinical signs and symptoms. Her clinical
manifestations are sunken eyes, depressed anterior fontanel,
5mL of urine output, frequent vomiting and watery stools,
high sodium and low potassium. Because gastroenteritis is
caused by an infectious pathogen, it most likely that
Harper’s condition is caused by a infection due to the lack
of immunizations since birth.
2. Urinary tract infections (UTI) are one of the most
common types of infection. A UTI is an infection that
occurs in any part of the urinary system due to an infectious
microorganism traveling up to the kidneys. Harper’s
laboratory results show that E. coli is present in her urine.
As a result of this, it is most likely that she has contracted a
UTI from the presence of E. coli that is found in the
intestines and in the rectum. There are many ways that the
urinary system is contaminated by E. coli. One way is that
the bladder was not fully emptied, she was put in a bubble
bath, is being washed with fragrant soaps, or if she was
wiped from the anus to her vagina (back to front).
Medical Management: Rationale: Expected Outcome:Collaborative Care: Nursing 3.
10
Admit to peds w/contact
precautions
Daily weight with strict I&O
Establish peripheral IV
0.9% NS @ 20 mL/kg bolus
over 30-60 minutes, then
maintenance of D5 0.9% NS
@ 4 mL/kg/hour
NPO if vomiting-may advance
small feedings of Pedialyte as
tolerated if no vomiting
acetaminophen 15 mg/kg
PO/Rectal every 4 hours PRN
for temp >101
Trimethoprim/sulfamethoxaz
ole PO 5mg/kg every 12 hrs
The patient is put on contact precautions to minimize
the chance of cross contamination since it is most likely
that an infectious and contagious pathogen caused her
medical issue. Some contact precautions include
wearing a gown and gloves. The healthcare
professional utilize hand hygiene on way into the room
and on the way out.
Daily weighing with strict intake and output allows
indication of hydration status and monitors for any
fluctuation in weight change. It is important because it
allows the patient to be adequately hydrated according
to weight per MD order.
It is essential to establish a patient peripheral IV for the
necessary administration of IV fluids and medication
administration. Peripheral site should be assessed for
patency, reaction at insertion site, and phlebitis.
Normal saline bolus was ordered to provide the child
with hydration, replace chloride, and replaced fluid and
electrolytes. IV fluids should be adequately given
according to weight and fluid amount to provide
correct rehydration. IV should be assessed for any
adverse reactions and if any infiltration, fluid overload,
or lung crackles occurs.
Rehydration is the most important intervention as the
patient was severely dehydrated. However, due to
frequent vomiting spells and inability to keep food
down, the patient has been ordered on NPO to retain
hydration status and prevent further vomiting. If
tolerated the patient could consume Pedialyte which
contains electrolytes that will further replenish the
child’s supply.
This medication is used to lower the temperature of
102.2 F. It will also minimize discomfort and pain.
Water loss that was lost from febrile episode will be
minimized which would increase hydration status. This
medication is preferred to minimize fever because it
lessens the chance that a pediatric patient will develop
GI upset rather than an NSAID which would irritate the
lining even further.
This medication is typically the drug of choice used to
treat urinary tract infections. It does so by inhibiting the
synthesis of the folic acid of the bacteria to prevent
further spread. It is common to have an allergy to sulfa
drugs. If a skin rash occurs, stop use and MD will
provide another medication effective in stopping the
spread of the infection.
This will prevent the spread of the
infectious pathogen. It also allows the
caretaker to be protected from potential
exposure. It is important to practice hand
washing to minimize any chance of
exposure.
Patient will become adequately hydrated
with 640mL/day or 26.67 mL/hr per weight
to minimize severe dehydration. Her
sunken eyes, depressed fontanel, and
lethargy will decrease as her urine output
will increase to a normal of 1-3 mL/ hour.
IV access will be established to provide the
child with adequate hydration due to severe
dehydration. Her blood pressure will
increase, kidney labs will increase due to
increase of perfusion, and urine output will
be increased.
As dehydration diminishes, all electrolyte
level will return to normal, blood pressure
returns to a normal level (95/58), HR
returning to a normal level of 80-150,
depressed fontanel rises, sunken eyes
diminish, and urine become clear with
around 6 diaper changes a day.
The patient will remain with no vomiting
spells to keep increasing hydration status. If
able, the patient will be able to tolerate
small feeding of Pedialyte which will
elevate her electrolyte levels of sodium to
135-145 and potassium of 3.5-5.
As a result of this medication, the patient’s
high temperature will gradually return to
normal limits of 96.8 F. 1 degree C every
hour is typically the standard to prevent
sudden change in temperature. Temperature
should be reassessed after the onset of the
medication of 15-20 minutes.
Urinary tract infection will be minimized if
not completely eradicated. If taken
correctly the patient should start seeing
improvement in the first 12-24 hours. The
patient will obtain clear urine, decreased
WBCs, more urine output of 1-3mL/ hr,
negative nitrates and negative LET.What nursing priority (ies) will guide your plan of care? (Management of care)
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial
Integrity/Basic Care and Comfort)
A psychosocial/holistic care priority for the child is bonding. The child and mother should be bonding further for
better relationship and interaction. By creating a bonding relationship, the mother could identify cues and
abnormal behaviors of the child before a serious condition were to occur due to the importance of subtle changes
making the difference when a child is unable to explain pain and discomfort. Per Erikson’s developmental stages,
trust vs. mistrust is stage that is of importance at this age. The child should be developing trust by bonding,
interactions, soothing tones, and being comforted through holding or caressing. The child’s emotional needs
should be met in addition to her medical needs. Taking care of the child emotionally is just as important for
development growth and socialization.
5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient
and/or family ? (Health Promotion and Maintenance)
Educational/ discharge priorities to promote health and wellness of the child would include interventions to
prevent future infection. For a urinary tract infection, the mother should wipe the child from front to back (from
vagina to rectum) this will prevent E.coli from reaching the urethra and causing an infection if it were to reach the
urinary system and eventually kidneys. The mother should be taught and should repeat back to the caregiver how
11
Nursing PRIORITY:
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
1. Vital signs should be assessed
every 4 hours to assess for baseline
and any abnormalities.
2. Hydration status should be assessed
every 4 hours for decreased
dehydration.
3. Urine output should be assessed to
be within normal parameter of
1-3mL/hr
4. Assess and monitor daily weight
1. Assessing baseline provides the
caretakers with a normal starting
point to note any fluctuations. For
hydration, blood pressure should be
around 95/58, HR of 80-150, and
temperature of 96.8 F.
2. 640mL/day or 26.67 mL/hr should
be maintained to provide the child
with adequate fluid for the size of
the child. Fontanels, eyes, capillary
refill, LOC, and lethargy should be
assessed to provide indication of
correct hydration.
3. Urine output should be 1-3mL/hr.
Assessing urine output is a correct
indicator of hydration status. If
adequately perfused, kidneys should
be producing urine that is clear and
free of sediment.
4. Daily weighting of the child
provides caregivers with indication
that there is hydration and no
abnormal weight loss or gain. It also
provides indication that the child is
not retaining too much fluid,
causing fluid overload and backup
into the lungs.
1. Vital signs will return WNL. HR will be
within 80-150 bpm, blood pressure around
95-58, temperature of 96.8 F, and
respirations of 30 breaths per minute.
2. Hydration will be reached. Fontanels will
no longer be depressed, eyes will not be
sunken, capillary refill will be less than 3
seconds, free of altered level of
consciousness, and no lethargy detected. The
skin will be pink, moist, and with moist
mucus membranes.
3. Urine output will be with 1-3 mL/hr.
Urine will be clear, free of sediment, obtain
no WBCs, no nitrates, and no LET. The child
will have around 6 diaper changes a day.
4. Weight will return to previous normal
weight of 15 lbs. 2 oz. The child will not
have any fluctuations that are greater than 1
lb. which indicate an abnormal finding,
meaning dehydration or retention of fluid
overload.to wipe for adequate prevention. The child so not be bathed in bubble baths due to the fragrance irrigating the
urethra which can suppress immunity. In addition, the mother should be educated on the importance of noticing
subtle details that are abnormal in the child. For example, the child should be urinating and going through about 6
diapers a day. This typically shows adequate fluid intake. If the child is not creating enough urine, a possible
infection has occurred. The child should be actively getting hydrated to prevent dehydration through calculation of
fluid status (640mL/kg/day). Another educational priority is to educate the mother on the importance of getting
her child immunized. The child is more susceptible to acquiring infections because the immune system is not fully
developed. The child can contract communicable diseases which could potentially be fatal to the child. Parvovirus,
rotavirus, chicken pox, Hepatitis B, Influenza, and many more can be contracted the child does not have the
antibodies or immunity to fight off such infection.
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