Question

Jalissa Twyman, 8 years old, was admitted to the pediatric intensive care unit with a closed head trauma after being involved in a bicycle/motor vehicle accident. Jalissa is unconscious. The nurses caring for Jalissa document a weight loss of 1.82 kg over a 24-hour period, decreased skin turgor, and dry mucous membranes. Urine output for the same 24-hour period is 3.5 L/m2. (Learning Objectives 1, 2, 3, 4, 5, and 7)

a. What further assessments should the nurse perform on Jalissa?

b. What laboratory tests would the nurse expect to be performed on Jalissa?

c. What nursing interventions should be done for Jalissa?

Answer 1

Answer-

Dehydration

​​​​​​​​(a) The most useful individual signs for identifying dehydration in Jalissa are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs.

(b) laboratory tests :

• Blood test -

-To check level of electrolytes

-BUN

-Creatinine.

• Urine analysis test

(c) Nursing intervention

• Provide extra fluid with meals, including juice, soup, ice cream and sherbet, gelatin, water on trays.

• Serve beverages at activities.

• All staff should encourage at least 60 ml of fluid of the resident's choice upon entering each resident's room.

• Encourage the resident to consume at least 180 ml with medications.