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Chapter 52

Nursing Care of a Family When a Child Has an Unintentional Injury

CD PATIENT SCENARIO

CARE STUDY: A GIRL WITH AN UNINTENTIONAL INJURY

Missy Long is a 14-year-old seen in the emergency room following an abdominal and

possible head injury.

CHIEF CONCERN:

She was hit by a hockey puck.

HISTORY OF CHIEF CONCERN:

Child was hit in the abdomen by a hockey puck while playing indoor ice hockey after

school. She fell following the accident and struck her face on the ice. She was

unconscious about 3 minutes following accident, has been sleepy since then, states

everything looks double, has vomited 3 times since accident. Clear fluid drains from

nose. Child was not wearing a helmet at time of accident. A front tooth, knocked out by

fall against ice, was dropped in water and brought in by coach.

FAMILY PROFILE:

Intact family; 2 younger siblings: 6-year-old twins. Mother works as a computer analyst;

father is an editor for evening newspaper. Family lives in a home in north suburb;

finances are described as adequate.

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PREGNANCY HISTORY:

Pregnancy was planned; birth was induced at 42 weeks for postterm pregnancy. Baby's

presentation was vertex. Breathed immediately. Mother unfamiliar with term Apgar.

No alcohol, smoking, or recreational drug use during pregnancy. Mother took aspirin for

frequent headaches throughout pregnancy.

HISTORY OF PAST ILLNESSES:

Frequent otitis media as an infant; serous otitis media beginning at age 5. Had

myringotomy tubes placed at 11 years; removed 6 months ago. Chickenpox at age 7

years. Poisoned self by swallowing acetaminophen at 3 years. Four stitches in chin at 8

years for fall at playground.

HISTORY OF FAMILY ILLNESSES:

Paternal grandfather and father both have had cardio-bypass surgery; a cousin was born

with an atrial septal heart defect. A paternal aunt has breast cancer. Mother has a positive

tuberculin reaction following exposure from a fellow worker; had a negative radiograph 1

month ago.

DAY HISTORY:

Nutrition: Eats all foods; favorites are pizza and corn on cob.

Sleep: Sleeps 8 hours at night; no difficulty falling asleep.

Play/Recreation: Participates in indoor ice hockey and soccer.

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Growth and Development: Child met infant and school-aged milestones. Currently in 9th

grade (age appropriate). Parents state child does well in school. Is happy and friendly

with peers. Menarche 3 months ago. Menses irregular; flow scant.

REVIEW OF SYSTEMS:

Negative but for chief concern and past illnesses.

PHYSICAL EXAMINATION:

Height: 150 cm (90th percentile). Weight: 40.6 kg (25th percentile). BMI: 20.3.

BP: 135/70.

General Appearance: Slim, well-proportioned, difficult to rouse 14-year-old. Two-inch

bleeding laceration in center of forehead surrounded by edematous area.

Head: Normocephalic; laceration as above.

Eyes: Left pupil dilated in comparison to right and reacts slowly to light. Inability to

follow light into superior oblique field; red reflex bilaterally. No ptosis. Fundoscopic

exam: no papilledema; disc edges distinctive. AV ratio 2/3.

Ears: TMs pink with landmarks and cone of light present. Difficult to document hearing

because of difficulty in rousing child; tear evident in right tympanic membrane with clear

fluid drainage in external ear canal.

Nose: Midline septum; nares patent. No discharge.

Mouth and Throat: Midline uvula; upper central right incisor absent. Slight bloody

oozing at sight. Mucous membrane moist.

Neck: Full ROM; no palpable lymph nodes; midline trachea.

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Lungs: Respiratory rate: 16 breaths per minute; no adventitious sounds.

Heart: Heart rate: 68 beats per minute; no murmurs; marked sinus arrhythmia

Abdomen: Tender to palpation; no bowel sounds present. Liver palpated 1 cm under right

costal margin.

Genitalia: Normal preadolescent female; Tanner 4.

Extremities: Full range of motion. One old ecchymotic bruise on calf of left leg

(yellow-brown); one on anterior surface of right lower leg (purple-red). Not asked to

walk because of mental confusion.

Neuro: DTRs: 1+ patellar and brachial on left; 2+ on right. Sensory: responds to

painful stimuli; motor: equal bilaterally. Babinski - flares on left foot. Kernig's sign:

negative.

Finger to Nose: Abnormal; Romberg: not attempted because of inability to stand

steadily.

Missy is diagnosed as having a coup concussion with a meningeal tear and an

avulsed front central incisor; possible abdominal trauma.

CARE STUDY QUESTIONS:

1. Missy is developing increased intracranial pressure from her head injury. A sign of

this from her health history is

a. temperature of 98.6F.

b. blood pressure of 135/70.

c. apical pulse of 100.

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d. anxiety and crying.

Answer: b. Increased blood pressure is a sign of increased intracranial pressure. 135/70

is elevated for a 14-year-old.

2. Missy is diagnosed as having a coup type of concussion. This means that

a. the posterior portion of her brain is injured.

b. her brain is injured just beneath her forehead.

c. she has diffuse injury throughout the brain.

d. she has no injury because the forehead took the blow.

Answer: b. A coup injury means the brain injury is beneath the skin lesion; a contrecoup

injury is at the opposite side.

3. Missy states she is unable to remember the hockey puck hitting her. This has

probably occurred because

a. loss of memory is a common finding following concussion.

b. she must be afraid that she will be blamed for the incident.

c. Missy hopes that she will receive more sympathy this way.

d. many young adolescents have poor memories for recent events.

Answer: a. A mark of concussion is that the individual has no memory of the incident.

4. Missys coach dropped her displaced tooth in water and brought it with him to the

emergency room. You would instruct him regarding this that

a. he should have replaced the tooth in Missys mouth.

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b. the best solution to use for this would have been milk.

c. as this was likely a baby tooth, he shouldnt have saved it.

d. teeth are too injured from this type of accident to try and save.

Answer: b. Milk or saline are the preferred solutions. Replacing it in the mouth of a

semiconscious child would not have been wise. At 14, it is unlikely this is a temporary

tooth.

5. Missy is prescribed a solution of Mannitol IV in the emergency room. The

purpose of this drug is to

a. decrease blood pressure.

b. increase blood glucose.

c. diminish pain sensation.

d. reduce intracranial pressure.

Answer: d. Mannitol is hypertonic so it causes fluid to shift from edematous tissue back

into the vascular system.

6. An important assessment to make after administering the Mannitol solution would be

a. blood pressure.

b. urine for protein.

c. pedal pulses.

d. color of mucous membrane.

Answer: a. As the blood stream fills with excess fluid, blood pressure can rise rapidly

until the fluid is detected and removed by the kidneys.

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7. Missy has clear fluid drainage from her nose. If this tested positive for glucose, you

would assess this as

a. lymphocytes collecting in the nasal sinuses.

b. her cerebral perfusion pressure is elevated.

c. possibly CSF from a meningeal tear.

d. blood serum collecting in her nasal sinuses.

Answer: c. Cerebral spinal fluid will test positive for glucose and can drain from the nose

or ear if there is a meningeal tear.

8. You assess that Missy opens her eyes to speech (score 4), has a motor response to pain

(score 5), and carries on a confused conversation (score 4), or has a Glasgow Coma

Scale score of 13. You would rate this as

a. severe trauma.

b. moderate trauma.

c. slight trauma.

d. no discernible trauma.

Answer: c. A Glasgow Coma Scale score of 13 to 15 indicates slight trauma.

9. Missy poisoned herself by swallowing acetaminophen (Tylenol) as a 3-year-old. The

antidote given for this in an emergency room is most frequently

a. syrup of ipecac.

b. activated charcoal.

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c. oral penicillin.

d. a bronchial dilator.

Answer: b. Activated charcoal effectively counteracts most ingested drugs. An

alternative drug would be mucomyst, a specific antidote for acetaminophen.

10. Why is iron such a dangerous drug when ingested in a poisoning?

a. It leads to extreme gastric irritation and bleeding.

b. It turns the skin a bronze or bright orange color.

c. It lodges in the intestine and causes obstruction.

d. It leads to bladder infection from bladder irritation.

Answer: a. Iron is extremely irritating to the stomach so it can cause gastric hemorrhage.

11. Why is lead poisoning so serious in young children?

a. It causes bones to weaken and fracture frequently.

b. It causes intestinal obstruction from lead balls.

c. It results in cognitive challenge from brain invasion.

d. Lead deposits in the eye globe and causes blindness.

Answer: c. Lead encephaly is extreme irritation and destruction of brain cells caused

by lead ingestion.

12. Missy has a tender abdomen from abdominal trauma. To rule out bleeding, the doctor

orders a paracentesis for her. This is

a. intraventous therapy to increase her blood pressure.

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b. insertion of an endoscopy tube into her intestine.

c. introduction of a catheter into her abdomen.

d. a radiograph study of liver or spleen blood flow.

Answer: c. A paracentesis is a procedure to assess for blood in the abdomen by inserting

a catheter into the abdomen.

13. Suppose you learn that Missy swallowed the overdose of acetaminophen, not at 3

years as you first learned, but a year ago when she was 13. Which would be your best

action?

a. Ask if Missy could have an IQ test as this suggests she is cognitively challenged.

b. Be alert that poisoning in adolescents could be a suicide attempt, not an accident.

c. Assess if Missy has difficulty reading small print so she could have misread the dose.

d. Alert Missy that overdoses of acetaminophen can lead to osteoporosis as an adult.

Answer: b. Children above beginning school age rarely poison themselves accidentally

so suicide attempts much be considered.

14. Missys father had a near-drowning incident as a child. If this occurred in saltwater,

you would observe most closely for which symptom?

a. Pulmonary edema from interstitial fluid moving into the lungs

b. Cerebral dehydration from fluid collecting in cerebral hemispheres

c. A dry, hacking cough that demonstrates salt-depleted lung tissue

d. Light headedness from hypernatremia from salt retention

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Answer: a. If saltwater (a hypertonic solution) enters the lungs, body fluid moves into the

lungs to dilute it. This can lead to pulmonary edema and decreased breathing space.

15. While Missy is hospitalized, one of her sisters is badly burned. When a burn is so

deep that it involves the blood vessels, which degree of burn is this?

a. Null degree

b. First degree

c. Second degree

d. Third degree

Answer: d. Burns that include the full thickness of skin including blood vessels and

nerves are third degree.

16. Twenty-four hours after a severe burn, which type of fluid movement would you

anticipate?

a. Edematous fluid moves into the vascular system, causing hypertension.

b. Fluid flows into the circle of Willis, generally increasing blood pressure.

c. Blood plasma pools in lower extremities and decreases cardiac output.

d. Fluid drains from the burn to the outside surface, resulting in hypotension.

Answer: a. Immediately following a burn, fluid flows into the burned site to bring with it

necessary white blood cells; at 24-hours post burn, fluid returns to the circulatory system.

17. If a child experiences a major burn, which complication would it be important to

observe for?

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a. Rapid breathing that indicates the child is still worried

b. Shivering, which could indicate skin is becoming permeable

c. Abdominal pain, which could be a sign of paralytic ilius

d. Stuttering when the child speaks as if still frightened

Answer: c. Paralytic ilius is a frequent complication of severe burns, resulting from the

systemic shock.

18. If a child with a severe burn is scheduled for debridement, this means that

a. the burned tissue will be sterilized with an antibiotic.

b. necrotic tissue at the burn site will be removed.

c. skin is grafted from another child to the burned child.

d. the bone under the burned area will be removed.

Answer: b. Debridement means that necrotic tissue will be surgically removed.

19. If a burned child has an escharotomy, this means that

a. the hard coating over the denuded area is cut away.

b. necrotic tissue at the burned site is removed.

e. granulation tissue is stimulated to grow rapidly.

c. a protection coating is applied to the burn site.

Answer: a. An eschar is the hard leather-like covering that forms over burns. An

escharotomy means the eschar is cut to prevent it from constricting circulation.

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20. Missys father reported that he was bitten by a poisonous snake when he was a child.

Emergency-room treatment for a venomous snake bite is to

a. elevate the bitten extremity to aid venous flow.

b. anticipate administering an antivenom serum.

c. apply a warm pack to the bite until it weeps.

d. keep the person talking to prevent unconsciousness.

Answer: b. Antivenom serum counteracts the effect of the poison. Any action that

increases blood flow (warmth, elevation, motion) is detrimental as it speeds flow of the

poison through the circulatory system.