infants/toddlers, maternal smoking, more than 2 children in the home, being born to an unwed mother, children with disabilities and children who live in a home with an unrelated relative (Cindy W. Christian, 2015, pp. e1337- e1354). Bruising may be the first sign of abuse (Chapple, 2015, pp. 288-292). • Pertinent negatives : no obvious deformities and no previous history of ER visits or care received for skeletal injuries. According to the mother this child has had many minor injuries that did not require medical attention. While minor injuries in children are common and do not require medical attention, the provider is taught to rely on parents for information about the child’s history and “may not be critical or skeptical of the information provided” (Cindy W. Christian, 2015, pp. e1337-e1354). Systemic Inflammatory Response Syndrome (SIRS) (R65.10) – is nonspecific and can be caused by many different insults such as ischemia, inflammation, trauma and infection and is characterized by two or more of the following: • Fever > 38°C (100.4°F) or < 36°C (96.8°F) • Heart rate > 90 beats per minute • Respiratory rate > 20 breaths per minute or arterial carbon dioxide tension (PaCO2) < 32 mm Hg • Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms) (Kaplan, 2018). Pertinent positives: patient presents with tachycardia, tachypnea, hypotension, elevated white count (Kaplan, 2018). Pertinent negatives: although the patient is dehydrated, the patient is still making urine, is afebrile and no acute respiratory process via radiograph Primary Diagnosis: Blunt abdominal trauma - patient presents with tachycardia, tachypnea, hypotension, diffuse abdominal pain, abdominal distention, visible abdominal bruising with tenderness and guarding on palpation and has old ligature marks to wrists, multiple various rib fractures old and new rib fractures in various stages of healing and a duodenal hematoma. Abdominal trauma is a serious injury that is commonly missed on initial diagnosis with the most injured organs being the spleen, liver, pancreas, kidneys, small bowel and bladder (Djordevic, Slavkovic, Marjanovic & Zivanovic, 2015, pp. 126-130). PLAN including education Plan: Air passage, breathing and circulation will be assessed. Place on cardiac monitor and pulse oximeter Place patient on oxygen to help manage hypoxia and admit to ICU Contact police, child protective services and involve case worker to help transition once healed and discharged from hospital care. Involvement of these entities will help determine safety of the child/children in the home and help set up continued care for the patient (Ihuman, 2019). Educate and inform the parent on what to expect regarding care of the patient (surgery, continued hospital care, etc) and just how ill the patient has become.
Summative Evaluation of the Case Study: While this case was difficult to execute, it is a wake call as to just how fragile and helpless children are. Child physical abuse is an important cause of pediatric morbidity and mortality that is associated with physical and mental health problems that can last a lifetime. It is estimated that each year, Child Protective Services (CPS) investigate more than 2
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