Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.
Explanation & Rationale
Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration. Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration. Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment. Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions. Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment. Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration. Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.