Initial nursing assessment child sitting on bed

Reference no: EM133708954

Initial Nursing Assessment Child sitting on bed, appears to have been crying. Alert and answers questions appropriately; PERRLA, sclera yellow. Lung sounds clear, respirations tachypneic at 40/min. Heart rate 108/min. Peripheral pulses palpable and strong. Capillary refill less than 3 seconds in bilateral upper extremities and less than 4 seconds in bilateral lower extremities. Oral mucosa pink and dry. Abdomen soft with active bowel sounds in all four quadrants. Child reports pain in abdomen and legs as 6 on FACES pain scale. Knees and hand joints are swollen, red, and warm to touch. Skin dry with poor turgor and tenting. The caregiver reports the child has had three hospitalizations in the past 8 months due to sickle cell crisis. The child's temperature is 38.3° C (100.9° F) and SpO2 is 88% on room air. Which of the following concerns should the nurse address while providing client care?

Physiological: Pain Physiological: Gas Exchange Physiological: Thermoregulation Physiological: Elimination Physiological: Inflammation Physiological: Metabolism Safety: Injury Prevention Health Promotion: Client Education Psychosocial: End of Life Physiological: Perfusion

Reference no: EM133708954

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Bilateral upper extremities : After performing the initial assessment, the child is tachypneic at 40/min, capillary refill less than 3 seconds in bilateral upper extremities

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