What is the nursing priority

Assignment Help Other Subject
Reference no: EM133323541

Case: Susie is a 6-month-old female who was brought into the emergency department for diarrhea and vomiting over the past two days. She had two 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 sleepier today. She is unable to keep any feedings down today. She has had 5 loose, watery stools and emesis x4 this morning. She has not had a wet diaper since yesterday evening. Susie has not had any immunizations since birth. She is 26 inches in length and weighs 16 pounds, 4 ounces. She weighed 17 pounds, 2 ounces at her last office visit two weeks ago. Susie's mother is 21 years old, a single mother, and this is her first child. Susie's mom is not currently working and lives with her parents and she feels overwhelmed as a new mother.

  1. What patient history has clinical significance to the nurse and why?

The most recent vital signs were:

T: 102.2 F/39.0 C (oral)

P: 158 (reg)

R: 36 (reg)

BP: 62/42

O2 sat: 95% on room air

  1. What patient vital signs have clinical significance to the nurse and why?

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
  • GI: Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness to palpation
  • GU: 5 mL dark amber, cloudy urine noted in urine collection bag-sent to lab
  • SKIN: Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no shiny saliva present, when skin over abdomen is pinched, remains tented for 2-3 seconds
  1. What patient assessment findings have clinical significance to the nurse and why?
  2. What is the nursing priority at this time?
  3. What nursing interventions will the nurse initiate based on the priority at this time?

Reference no: EM133323541

Questions Cloud

How did your decisions impact your goals in years 54-62 : Looking back at the entire simulation experience, what can you draw about the relationship between business ethics and professional advancement?
Describe the influence of slaves on the diets of their owner : Describe the influence of slaves on the diets of their owners and on Southern food culture as a whole. Give 3 specific and clear examples. Number you responses.
Identify anticipated or expected learner needs : Develop a teaching plan based on an assigned scenario, case, or client interview. Determine what elements you would include in your assessment of the learner
What is the role of the catholic church : What methods do they use to protest? What is the role of the Catholic Church? How did the poor economy help those opposed to Pinochet?
What is the nursing priority : What is the nursing priority at this time and What nursing interventions will the nurse initiate based on the priority at this time
Explain how would you design a marketing program : Explain, how would you design a marketing program for your company using the elements of the marketing mix and market segmentation?
What is jesus advice for mental health : What is Jesus' advice for mental health in 6:25-34? Explain his philosophy and how it can relate to your or anyone's life.
Determine the gdp, mean income, culture, inflation rate : Determine the GDP, mean income, culture, inflation rate and other economic factors. Determine the feasibility of the US conducting business with this country.
Compare three ways to disseminate research findings : Methods of Dissemination - Compare three ways to disseminate research findings. Formatted and cited in the current American Psychological Association style

Reviews

Write a Review

Other Subject Questions & Answers

  Cross-cultural opportunities and conflicts in canada

Short Paper on Cross-cultural Opportunities and Conflicts in Canada.

  Sociology theory questions

Sociology are very fundamental in nature. Role strain and role constraint speak about the duties and responsibilities of the roles of people in society or in a group. A short theory about Darwin and Moths is also answered.

  A book review on unfaithful angels

This review will help the reader understand the social work profession through different concepts giving the glimpse of why the social work profession might have drifted away from its original purpose of serving the poor.

  Disorder paper: schizophrenia

Schizophrenia does not really have just one single cause. It is a possibility that this disorder could be inherited but not all doctors are sure.

  Individual assignment: two models handout and rubric

Individual Assignment : Two Models Handout and Rubric,    This paper will allow you to understand and evaluate two vastly different organizational models and to effectively communicate their differences.

  Developing strategic intent for toyota

The following report includes the description about the organization, its strategies, industry analysis in which it operates and its position in the industry.

  Gasoline powered passenger vehicles

In this study, we examine how gasoline price volatility and income of the consumers impacts consumer's demand for gasoline.

  An aspect of poverty in canada

Economics thesis undergrad 4th year paper to write. it should be about 22 pages in length, literature review, economic analysis and then data or cost benefit analysis.

  Ngn customer satisfaction qos indicator for 3g services

The paper aims to highlight the global trends in countries and regions where 3G has already been introduced and propose an implementation plan to the telecom operators of developing countries.

  Prepare a power point presentation

Prepare the power point presentation for the case: Santa Fe Independent School District

  Information literacy is important in this environment

Information literacy is critically important in this contemporary environment

  Associative property of multiplication

Write a definition for associative property of multiplication.

Free Assignment Quote

Assured A++ Grade

Get guaranteed satisfaction & time on delivery in every assignment order you paid with us! We ensure premium quality solution document along with free turntin report!

All rights reserved! Copyrights ©2019-2020 ExpertsMind IT Educational Pvt Ltd