Client Name: Taylor Hicks Gender: Female Race:
Client Name: Taylor Hicks Gender: Female Race: Caucasian Age: 07 months Weight: 9 lbs 2 oz Height: 26″ Location: Peds Unit Allergies: NKDA Immunizations: UTD Physician: Dr. J Brown Admitting Diagnosis: Gastroenteritis and Dehydration Client Information: Taylor, a 07-month-old female, presented to clinic this am with progressively worsening of symptoms associated with GI disturbances. Not eating well, pale, diaphoretic, and slightly depressed fontanels noted, respiratory: clear bilaterally.. Heart: RRR; PERRL; tachypnea; poor appetite. Sent from office to ER to receive Tylenol, and to be admitted. Past Medical History: 32 week gestation; complicated delivery, transferred to UVA and on ventilator for 10 days on arrival , home oxygen required at home until 5 months of age, has been hospitalized 3 times for RSV bronchiolitis since birth. Has been in clinic for well visits and immunizations are up to date. Social History: Mother attentive to only child. Single mother father no longer part of family. Mother reports that child care provider does smoke. No animals in household, wood stove heat. Surgeries/Procedures: None Directions: Answer the questions based upon the client information. 1. Taylor Hicks is being admitted with Gastroenteritis and Dehydration. What assessment data do you as the nurse need to obtain? 2. What assessment findings do you expect to find in a 7-month-old with regards to normal growth and development? Where does Taylor fall on the growth charts? 3. What assessment findings do you expect to find in a 7-month-old with gastroenteritis and dehydration? 4. Review the provided lab values and provide rationale for abnormal findings. 5. Identify three possible nursing diagnoses with interventions that you may implement for Taylor Hicks. 6. How will you evaluate your interventions effectiveness? SCIENCE HEALTH SCIENCE NURSING NUR 328
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