Luna is a 6-month-old female who was brought into the physician’s
Question Answered step-by-step Luna is a 6-month-old female who was brought into the physician’soffice 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 refusing the bottle, and is not interested in playing, and has been more sleepy today.She has had six loose, watery stools and emesis x2 this morning. She has not had a wet diaper since yesterday evening. She is 25 inches in length and weighs 14 pounds, 2 ounces. She weighed 16 pounds, 1 ounce at her last office visit two weeks ago. Luna has been admitted to your unit. 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 and lives with her parents. Though she has strong social support from her parents, she feels consistently overwhelmed as a new mother.Past Medical History (PMH): Healthy full-term infant that weighed 6 pounds 10 ounces at birth. No current health problems. Mom is no longer breastfeeding and Harper is on formula. Mother had no complications with pregnancy. Has not had any immunizations from birth, including rotavirusVital Signs: T: 102.2 P:158 R: 38 BP: 62/42 O2 Sat: 95% RAAssessment: GENERAL APPEARANCE: Irritable when awake, alternates with lethargy once quiet, when awake and crying, tears are not presentRESP: Breath sounds clear with equal aeration bilaterally, non-laboredCARDIAC: Skin is pale, cool to touch, cap refill 3-4 seconds in both hands, brachial pulses palpable bilaterallyNEURO: Lethargic, does not maintain eye contact with mom or caregiverGI: Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness to palpationGU: 5 mL dark amber, cloudy urine noted in urine collection bag-sent to labSKIN: Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no shiny saliva present when the skin over abdomen is pinched, remains tented for 2-3 secondsLabs:Basic Metabolic Panel (BMP)Na: 151 K: 3.1 Cl: 92 C02:15 Gluc: 102 Creat: 1.4 CBCWBC: 19.8 HGB:15.2 PLT’s: 215 % Neuts: 88 1. Analyze the assessment data and identify red flags (Provide rationales). 2. After reviewing the assessment data, identify the primary problem. 3. What interventions will be anticipated in this scenario? 4. What education should the nurse plan for at discharge? Health Science Science Nursing NUR MISC Share QuestionEmailCopy link Comments (0)
