Mary is a 12 month old who has been vomiting for the past 12 hours. Mary woke up at 5 AM but has not been able to “hold anything down”. Mary’s mother is concerned because it is now 4:00 pm. Mary’s mother calls the primary care office and is recommended by the nurse to have Mary evaluated at the clinic (Dr. Office). On initial assessment, Mary is lethargic and very quiet. She has mild nasal congestion and Her lips and skin are dry. She occasionally cries, but does not produce tears. Mary’s diaper has not been changed since 5 am and is currently dry upon this visitation to the clinic. Note: The season is late winter.
Mary lies very quietly on the examination table. Her vital signs are:
Temperature: 101.1O F or 38.3 C
Apical Rate: 153 bpm
Respiratory Rate: 42 breaths per minute
Blood pressure 90/48
Birth weight: 8 lbs
Current weight: 21 lbs
Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz
A fluid bolus is ordered by the physician and after administration of the bolus; Mary perks up a little bit. The doctor then orders Tylenol for the patient.
Mary’s laboratory values come back as follows:
The nursing diagnosis can be described as followed
As the patient is an infant,her temperature is slightly high.she may be infected with any medicines or it may be due to food she have conceived.the creatine level of the baby is higher than the normal value.the patinet had vomited and she seems to be dehydrated,where we can find it from her physical appearance and there is mentioned that her diaper is still wet,though she had wore it from morning.the medicine tylenol is best for the best because it is suitable for pain and fever.
At the first level it may diagnose vomiting , fever,dehydration. but it continues it may extend death.because that much severe dehydration is there, we can see that , her tears also not there when she is crying.
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