a Upon physical examination the patient was seen to have blunt abdominal trauma

A upon physical examination the patient was seen to

This preview shows page 5 - 7 out of 7 pages.

a. Upon physical examination, the patient was seen to have blunt abdominal trauma based on the patients acute abdominal findings with associated circulatory and neurologic compromise (shock) (Khan, 2012). Abdominal trauma contributes to 50% of child abuse fatalities (Burns et al., 2016). The patient has duodenal hematoma from blunt force trauma by form of punching from the mothers boyfriend. 2. Systemic Inflammatory Response Syndrome (R65.10)- is the bodies response to an infection or non-infection insult resulting in inflammation throughout the body (Burns et al., 2016). a. SIRS criteria for diagnosis is based on temperature > 38 degrees Celsius or < 36 degrees Celsius, Heart rate > 90, Respiratory rate > 20 or PaCO2 < 32 mm Hg, or WBC > 12,000/ m3, < 4,000/mm3 or > 10% bands (Burns et al., 2016). The patient, T.A., had a WBC of 19,000, heart rate of 160 bpm, systolic blood pressure of 68, and respiratory rate of 50, thus, meeting 4 out of the 5 common findings in SIRS. 3.Child abuse (T74.12XA)- physical maltreatment or sexual molestation of a child (Burns et al., 2016). References Revised 5/9/18; 8/9/18; 10/29/18
Image of page 5
Pediatric SOAP Note Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2016). Pediatric primary care: A handbook for nurse practitioners, (6 th ed.). Philadelphia: Saunders. Khan, S. (2012). Functional Abdominal Pain in Children. Retrieved from Revised 5/9/18; 8/9/18; 10/29/18
Image of page 6
Pediatric SOAP Note Revised 5/9/18; 8/9/18; 10/29/18
Image of page 7

You've reached the end of your free preview.

Want to read all 7 pages?

  • Summer '17
  • Burns, Penetrating trauma, blunt trauma

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture