(^174) Pediatric Nursing Demystified
Further exploration:Assess client’s vital signs along with what other
elements daily?
Follow-up assessments and monitoring: The nurse watches Adam
closely for fluid balance including urine output (becoming lighter gold in
color with hydration, 30 cc/hour), weight (4.4 kg below is normal range
on admission, but now only 3 kg below normal range ), and continues
intake and outputs. The nurse also watches for signs of anemia (realizing
the hematocrit was within range because the client was hemoconcentrated
and after rehydration the level will likely drop).
Evaluation and continued care:The nurses perform full assessments
every 12 hours. Daily weights reveal weight gain of 1 pound after
1 week of treatment with six small high-calorie meals. Chemotherapy
is tolerated well without nausea and vomiting and with administration
of antiemetic. Adam moves into a remission of the leukemia. Skin is
warm to touch with capillary refill in extremities <3 seconds. Mucous
membranes begin to look moist, and urine color becomes clear and
pale yellow with fluid intake of 8 ounces every 2 hours. The nurse
instructs the mother to stop pushing fluid between meals and provide
drink as requested by child because dehydration seems to have
resolved. After further teaching, the mother voiced understanding of
follow-up visits after discharge to monitor for condition change or con-
tinued remission.
Answers for the Case Study
- Immature lymphocytes are noted, indicating acute lymphoid
leukemia (ALL).
2.Interpretation:The nurse suspects malnourishment and dehy-
dration because of the low protein and poor skin turgor and dehy-
dration because of the dry tongue and mucous membrane and
concentrated urine. The low RBCs, platelet, and WBC levels
indicate anemia and reduced blood cell production from the
leukemia.
3.Follow-up:Daily weight, skin turgor, and activity tolerance,
note daily lab results, particularly hematocrit, protein, as well as
bloodcells—RBC, WBC—to determine hydration, nutrition, and
anemia status.