The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.

What action should the nurse take first?

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

= Answer is... Choice A. Severe skin breakdown in the diaper area.

Choice A rationale:

In the case of the 3-month-old infant presenting with difficulty sleeping through the night, severe skin breakdown in the diaper area is the most significant finding requiring attention in care planning for this family. Diaper dermatitis, characterized by erythema, edema, and erosion of the skin in the diaper region, can cause considerable discomfort and distress to the infant. Moreover, severe skin breakdown increases the risk of secondary infections and exacerbates the infant's discomfort, potentially impacting sleep patterns and overall well-being.

Diaper dermatitis often results from prolonged exposure to urine and feces, friction, and the occlusive environment created by diapers. The acidic pH of urine and feces, coupled with the breakdown of urea into ammonia, contributes to skin irritation and inflammation. Additionally, the warm, moist environment beneath the diaper provides an ideal breeding ground for microbial overgrowth, further exacerbating skin damage.

Management of severe diaper dermatitis involves a multifaceted approach, including frequent diaper changes, gentle cleansing of the affected area, application of barrier creams or ointments, and promotion of air exposure to facilitate healing. In severe cases, topical corticosteroids or antifungal agents may be prescribed to reduce inflammation and prevent secondary infections.

Preventing and managing diaper dermatitis is essential not only for alleviating the infant's discomfort but also for promoting uninterrupted sleep patterns. Discomfort associated with diaper rash can lead to increased irritability and difficulty settling down for sleep, contributing to sleep disturbances for both the infant and the caregiver. By addressing the underlying cause of the skin breakdown and implementing appropriate interventions, healthcare providers can support the family in improving the infant's comfort and sleep quality.

Choice B rationale:

The mother stating that the baby is irritable during feedings is indeed noteworthy and may indicate various underlying issues, such as feeding difficulties, gastrointestinal discomfort, or inadequate milk supply. However, while irritability during feedings can contribute to disrupted sleep patterns, it is not as directly relevant to the immediate concern of severe skin breakdown in the diaper area. Nonetheless, addressing feeding concerns is essential for optimizing the infant's nutritional intake and overall well-being.

Choice C rationale:

The mother being a single parent and living with her parents provides contextual information about the family's social support structure but is not directly related to the infant's difficulty sleeping through the night or the significant finding of severe skin breakdown in the diaper area. While family dynamics and support systems play a crucial role in caregiving and may influence the implementation of care strategies, they do not directly address the infant's current health issue.

Choice D rationale:

The fact that the infant's formula has been changed twice may indicate attempts to address feeding-related concerns or suspected formula intolerance. While changes in formula may impact the infant's gastrointestinal comfort and feeding patterns, they do not directly address the primary concern of severe skin breakdown in the diaper area. Nonetheless, evaluating the appropriateness of the current formula and addressing any feeding-related issues remain important aspects of comprehensive care for the infant.