Pediatric Gastroenteritis Case Study,, UNFOLDING Reasoning, Harper Anderson, 5 months old, (Latest 2021) Correct Study Guide,

Pediatric Gastroenteritis Case Study History of Present Illness: Harper Smith is a 5-month old female who was brought into the Urgent Care for diarrhea and vomiting over the past 2 days. Her mother reports that she has bene less active and not interested in playing and has been sleepier than normal today. She is unable to keep any feedings down today. She has had 4 loose, watery stools and emesis x3 since this morning. She has not had a wet diaper since yesterday evening. She is 25 inches in length and weighs 14 pounds. She weighed 8 kgs at her last check up visit 2 weeks ago. Harper is admitted to the pediatric unit where you are the nursing student helping the nurse with her care for the day. Personal/Social History: Harper’s mother, Nicole, is 21-years old. She is a single mother, and this is her first child. Nicole is a first-year nursing student who lives with her parents until she completes her degree. Past Medical History ealthy, full term infant that weighed 6 pounds 10 ounces at birth. No current health problems. Mom is no longer breast feeding and gives Harper Similac Sensitive formula. Mother had no complications with pregnancy. Current Vital Signs Temp: 102.2 Axillary Pulse: 158 Resp Rate: 38 BP: 62/42 O2 Sat: 95% on RA Current Assessment: General Appearance: Irritable when awake; alternates with lethargy once she is quiet; when she is awake and crying, she has no tears Respiratory: Breath sounds are clear with equal aeration bilaterally, non-labored Cardiac: Skin is pale, cool to touch, cap refill 4 seconds in both hands, brachial pulses palpated bilaterally Neurological: Pupils equal and reactive to light; does not maintain eye contact with nurse or mother; lethargic off and on; fontanel slightly sunken Gastrointestinal: Abdomen soft & rounded; active bowel sounds in all 4 quadrants; no apparent tenderness with palpation Genitourinary: 5mL of cloudy urine noted in urine collection bag; lab confirms UTI Skin: Anterior fontanel sunken in; lips and tongue are dry; no saliva noted; when skin over abdomen is pinched it remains tented for 3 seconds ……………………………………….CONTINUED……………………………………