diarrhea, no confusionDuodenal hematoma-K26.0-Occurs secondary to blunt abdominal force especially in children because the abdominal wall is not very strong in protecting internal organs. As a result of the blunt force trauma, a hematoma forms in the duodenal wall (Hollier, 2018).TBI- S06.2X9D-brain injury caused by blunt force to the head (Hollier 2018). R/O-Normal head CT. No decreased consciousness, blackout, seizures, racoon eyes, fainting, uneven pupils, dilatedpupils. Patient S/S-fatigue, vomiting. No bruising on head (Luyet, Wipperfurth, Palm, & Knox, 2016) No racoon eyes, fainting, dizziness, dilated pupils.SIRS-E65.10- R/I-An inflammatory state that affects the whole body. Characterized as fever above 38.0 C or below 36 C, heart rate above 90 bpm, tachypnea grater than 20, leukocytosis WBC greater than 10, or leukopenia less than 4 (Hollier, 2018). At least two of the above criteria
need to be met- Pt S/S- tachypnea-50, tahcycardia-140.Hirshrungs-Q43.1-Missing nerve cells inn colon that causes difficulty in passing stool (Hollier, 2018)- R/O-No reports of difficulty passing stoolsHenoch-schonian purpura-D69.0-small red and raised areas of bleeding under the skin usually and extremities and buttocks. S/S- Joint and abdominal pain, constipation, diarrhea (Hollier, 2018). Pt S/S- Abdominal pain. Non diarrhea, no joint involvement, no purpura spots.Volvulus-K56.2-Bowel obstruction due to twisting or knotting/S-blood in stool, vomiting green bile, distended abd, dehydration, lump inn abdomen. R/O-Pt s/s tender abdomen, distended abd. No vomiting green, no bloody stool, no abdominal mass, no evidence on ABD CT (Hollier, 2018),Child negleck-T76.6- Caregiver or parent failure or delay in providing for needs of the child (Bütün, Ayhan, & Beyazit. (2019).). Pt S/S- dental caries, diaper rash, has not had immunizationsup to date.DiagnosesPrimary Diagnosis-Child abuse- Child abuse: ICD-10-CM T76.12XA - The Child Abuse Prevention and Treatment Act, characterizes child abuse as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “an act or failure to act which presents an imminent risk of serious harm.”7Although each state has their own definition of child abuse, most states recognize 4 major types of child abuse. These include neglect, physical abuse, emotional abuse, as well as sexual abuse (Kodner & Wetherman, 2013)Secondary DiagnosisBlunt force trauma- S39Duodenal hematoma-K26.0SIRS- E65.10PlanVaccines administered:None dueInitial resuscitation and stabilization:Assess ABC’S.Admit Tommy to ICU for further management. Begin continuous cardiac monitoring andContinuous pulse oximeterContinuous B/P to monitor vital signs.
Strict intake and output monitoring- Initial stabilization and maintaining ABC is first priority(Ayhan, & Beyazit, 2019).
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- Summer '17
- NSG6435 Discussion