A mother brings her 8-month-old infant, Mary, to the primary care clinic. The mo

Question

A mother brings her 8-month-old infant, Mary, to the primary care clinic. The mother reports that Mary has had a cold for about 2 days, and this morning she began to vomit and has had diarrhea for the past 8 hours. The mother states that Mary is still breastfeeding, but that she is not taking as much fluid as usual, and she is having three times as many stools as usual (the stools are watery in consistency). When the nurse examines Mary, she notes that her temperature is 100.4° F, her pulse and blood pressure are in the normal range, her mucous membranes are moist, and she has tears when she cries. The nurse also notes that Mary's weight has not changed from what it was when she was seen in the clinic 2 weeks ago for her well-child visit.

List the three priority assessments the nurse should perform. Provide a rationale.

Explanation / Answer

According to the given situation the 8 years child is suffering from vomiting, fever, reduced fluid intake and frequent stools. So due to the above symptoms a nurse can easily concluded the infant is suffering from GI tract infection and dehydration.

Dehydration was classified into various ranges from mild to serve (acute) manifestation and the diarrhea can be caused due to various factors but treatment is completely depends the causative agent.

Child history and examination:

Detect severity of dehydration, if present, and determine the degree of severity;

Evaluate the child's nutritional status

Diagnose persistent diarrhoea, if present;

Check the child's immunization history (especially measles)

Diagnose any concurrent illness

Clinical assessment:

Prepare proper plan to prevent dehydration

Recommendations for feeding during and after diarrhoea

Prepare proper plan for treating persistent diarrhoea

Prepare proper plan to managing any concurrent illness

Recommend for measles immunization

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