Alison is a 12 month old who has been vomiting for the past 12 hours. Since waking at 6 AM she has “not held anything down.” It is now 5:30 PM and Alison’s mother is becoming concerned. She calls the primary care office and the nurse recommends that Alison be brought into the office for evaluation. On initial assessment, Alison is lethargic and very quiet. Her lips and skin are dry. She is crying at times, but does not produce tears. Her diaper is dry; her mother says that she has not needed to change her diaper since 7 AM.
What are your primary concerns based on these findings?
Alison lies very quietly on the examination table. Her vital signs are:
Temperature: 101° F
Apical Rate: 150 bpm
Respiratory Rate: 40 breaths per minute
Blood pressure 90/48
Birth weight: 8 lbs
Current weight: 21 lbs 6 oz
Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz
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What are you concerned with now
Alison’s mother reports that she loves her milk and usually drinks about 40 ounces per day. However, for the past 24 hours she has not wanted anything to eat or drink. Her mother wants to know if there is anything that the nurse can give Alison to help stop the vomiting.
What questions does the nurse need to ask mother at this point?
What is your assessment of Alison’s vital signs?
Describe your approach to Alison’s physical exam.
Some of your physical exam findings:
Chest congestion and bilateral coarseness with a slight expiratory wheeze, dry cough, nasal congestion, left tympanic membrane is bulging and erythematous and Alison seems bothered when the nurse touches her ears
Alison lies quietly throughout physical exam. What concerns do you have?
Alison is beginning to cry and her mother asks is she can give her a bottle. She hands the bottle to Alison and Alison refuses to hold her own bottle. When asked, her mother says, “Oh she is just lazy. She won’t stand up on her own either!”
Why does this concern the nurse?
Alison’s laboratory values come back as follows:
• Hgb-11 Gm
• WBC-10,000 mm³
• Potassium- 4.2 mEq/L
• Sed rate- 10 mm/hr
• Creatinine-5 mg/dL
• BUN-7 mg/dL
• CO2-15 mEq/L
• UA-small amount of leukocytes, negative nitrites, large ketones
• Blood and Urine cultures-pending
• Blood glucose-75 mg/dL
What laboratory values are concerning?
What do you suspect are the diagnoses for Alison?
What is the plan of care for Alison at this point?