95%(22)21 out of 22 people found this document helpful
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 traumaby form of punching from the mothers boyfriend. 2.Systemic Inflammatory Response Syndrome (R65.10)- is the bodies response to an infectionor 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).ReferencesRevised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP NoteBurns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2016). Pediatric primary care: A handbook for nurse practitioners, (6thed.). Philadelphia: Saunders. Khan, S. (2012). Functional Abdominal Pain in Children. Retrieved from Revised 5/9/18; 8/9/18; 10/29/18