A nurse is assessing patients in the pediatric intensive care unit for signs of hypoperfusion. Which assessment findings are indicative of this condition? (Select all that apply.)
A.
Capillary refill: 2 seconds
B.
Mean arterial pressure: 32 mm Hg
C.
Mental status: lethargic
D.
Pedal pulses: bounding
E.
Urinary output: 2 mL/kg/hour
ANS: B, C
Signs of hypoperfusion include urinary output less than 1 mL/kg/hour, mean arterial pressure less than 45-50 mm Hg, decreased peripheral and pedal pulses, tachycardia, mental status changes, lethargy, delayed capillary refill, and pallor. A capillary refill of 2 seconds is normal. Mean arterial pressure of 32 mm Hg is too low and is indicative of hypoperfusion. Lethargy is a sign of hypoperfusion. Bounding pedal pulses may indicate fluid overload, and a urine output of 2 mL/kg/hour is normal.
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