Chapter 49: Nursing Care of the Child With an Endocrine
Disorder
1. Jalissa Twyman, 8 years old, was admitted to the pediatric intensive care unit with a closed
head trauma after being involved in a bicycle/motor vehicle accident. Jalissa is unconscious.
The nurses caring for Jalissa document a weight loss of 1.82 kg over a 24-hour period,
decreased skin turgor, and dry mucous membranes. Urine output for the same 24-hour period is
3.5 L/m2.
a. What further assessments should the nurse perform on Jalissa?
b. What laboratory tests would the nurse expect to be performed on Jalissa?
c. What nursing interventions should be done for Jalissa?
2. Aellai% , 13 years old, is brought to the clinic by her mother, who states Gianopoulos
that Aellai is losing her hair. Vital signs are as follows: T 98.4°F, HR 85, R 15, BP 121/78.
Height is 64 in., and weight is 81.5 kg.
Aellai has an olive complexion marred by acne, large brown eyes, and long black hair
that is very thin on the top of her head. Her breasts are small and she has an abundance
of hair on her arms and legs. She reached puberty approximately 6 months ago.
a. What other information should the nurse gather in the health history?
b. What laboratory tests would the nurse expect to be ordered for Aellai?
c. What should the nurse include in the teaching plan for Aellai and her family?
What further assessments should the nurse perform on Jalissa?
Based on the information provided, Jalissa is exhibiting signs of fluid deficit or dehydration. To further
assess Jalissa's condition, the nurse should perform the following assessments:
Vital signs: Assess Jalissa's heart rate, blood pressure, respiratory rate, and temperature. These
measurements can provide important information about her overall cardiovascular status and any signs
of compensation.
Capillary refill: Assess the capillary refill time by pressing on Jalissa's fingernail or fingertip and observing
the time it takes for the color to return. Delayed capillary refill may indicate poor perfusion.
Neurological assessment: Monitor Jalissa's level of consciousness, pupil size and reaction, and any signs
of neurological deterioration. This is important to evaluate the extent of her head trauma and identify
any changes in her neurological status.
Skin assessment: Inspect Jalissa's skin for signs of poor perfusion, such as pallor or mottling. Check for
any signs of pressure ulcers or skin breakdown, as immobilized patients are at higher risk.
Mucous membranes: Assess the moisture level of Jalissa's mucous membranes, including her oral cavity
and conjunctiva. Dry mucous membranes can indicate dehydration.
Edema assessment: Check for the presence of edema in Jalissa's extremities, face, or dependent areas.
This can provide additional information about her fluid status.
Laboratory tests: Order laboratory tests, including complete blood count (CBC), electrolytes (sodium,
potassium, chloride), blood urea nitrogen (BUN), creatinine, and urine specific gravity. These tests can
help evaluate Jalissa's fluid and electrolyte balance and guide further treatment.
Remember to involve the healthcare provider in assessing Jalissa and discussing the findings to ensure
appropriate interventions are implemented promptly.
Here are some additional assessments that the nurse should consider performing on Jalissa:
Fluid balance assessment: Monitor intake and output accurately to determine if there is a fluid
imbalance. Measure and record all fluids Jalissa receives, including intravenous fluids, oral intake, and
