Pertinent negatives: patient is still making urine, patient does not have any blood in the stool or rectum, patient only had one episode of vomiting and no previous recorded ER visits for injuries. (Burns et al, 2016) o Rationale: According to Goolsby (2014), a child that presents in a shock like state, but is still producing urine and has no blood in the stool could be experiencing incarcerated hernia or a volvulus. Child Abuse- Acts of Commission (T76.12XA)) Pertinent positive: patient has multiple new and old rib fractures in various stages of healing, the patient has visible ligature marks to bilateral wrists, the patient has diffuse bruising to abdomen, the mother reports the patient is “very clumsy” frequently injuring himself, the mother also admits to being a single mother of multiple children and having a stressful living situation with a medically needy child. (Burns et al, 2016) o Rationale: According to Goolsby (2014), Medically needy children are at increased risk to suffer from child abuse. This patient’s mother also experiences increased stress levels due to being a single providing parent for multiple children. When multiple reports of injuries are given, along with visible ligature marks, multiple various stages of healing rib fractures and small size and stature, it can reasonably be concluded that there is some level of child abuse happening in the home. Pertinent negatives: Patient does not have any obvious deformities or any neurologic symptoms. The patient has not had multiple ER visits for previous injuries. (Burns et al, 2016) o Rationale: According to Goolsby (2014), child abuse victims many times will have obvious deformities, also, those with shaken baby symptomology will have neurologic deficits. Statistics show that traumatic brain injuries and blunt abdominal trauma are the two leading causes of death from child abuse. Systemic Inflammatory Response Syndrome (R65.10) (SIRS) Pertinent positive: patient arrives with tachycardia, tachypnea, hypotension, elevated white count and elevated lactic acid level. (Burns et al, 2016) o Rationale: According to Goolsby (2014), children with these symptoms, meet four of the five SIRS criteria, only needing two to be SIRS positive, this patient is likely in shock or heading towards sepsis rapidly. Pertinent negative: patient is still making urine, does not have any fevers, and has negative radiographic studies for respiratory infection. (Burns et al, 2016) o Rationale: According to (Goolsby, 2014) pediatric patients are more likely to become septic from respiratory infections than other infections. Due to the fact that this patient is still making urine and not having any fevers are keys to differentiating between shock and sepsis. Primary diagnosis 1. Blunt Abdominal Trauma (S39.9) o Rationale: T.A. presents with tachycardia, tachypnea, hypotension, diffuse abdominal pain, visible abdominal bruising, abdominal distention, firmness, tenderness and guarding with old ligature marks to wrists, multiple various rib fractures, small stature and weight, history of being medically needy, a child of a multi-sibling family to a single mother and is listless. This child is clearly in distress and shows signs of shock and hypoxia.
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