Manmeet kaur and Ramanjot kaur
Kate Squires, RN, BScnOctober 15, 2018
Medicine Hat College
This morning at 0700, my charge nurse, Kate Squires, RN, BScN (October 15, 2018), gave me the report of C.K., a 10-month-old infant who was brought into the emergency room by her mother Katrina, a 17-year old single parent because her child is “sleeping too much, eating poorly and is too thin.”. Katrina was accompanied by her 19-year old boyfriend. Furthermore, the mother said that her main concern is that her daughter is suddenly “having trouble breathing and coughing and she is making some weird sounds while breathing.” The charge nurse assesses the infant and notes the infant to have poor hygiene, a dirty diaper with dried stool, lower than expected body weight (10th percentile on a national growth chart), lethargy, and large wide eyes. Also, the nurse noted that the infant does not demonstrate stranger anxiety and she does not smile when the nurse attempts to play with her rather looks irritable and fussy. Upon further assessment, it was revealed that the child has a yellowish bruise on her lower flank and a new bluish bruise on her upper right chest.
Upon my further assessment with infant’s mother, she stated that she is very stressed as C.K. was an unwanted child. Her boyfriend is the father of the child. He never wanted a child and hence forces her to give C.K. up in foster care because he thinks they both are too young to take responsibility of a child and it is affecting their relationship. The mother has now dropped out of her high school because of her child. She has no financial support from her boyfriend for childbearing. So, to support her child and herself she works during the days and leave the baby with her boyfriend. When I tried to ask her boyfriend some questions about the baby he did not engage into any conversation and remained focused on his cell phone.
Upon my physical assessment on infant, I noted that, her right upper chest was bruised, swollen and tender to touch. When I touched her chest, she closed her eyes tightly, wrinkled her eyebrows, grimaced and started crying with mouth wide open. Her chest rise was asymmetrical. While breathing, wheezes were heard. She weighs 13.2 lbs. (6kg). Vital signs: HR- 135 bpm, BP – 120/75, RR-46 breaths/minute, rapid and shallow, T- 39 degrees Celsius (axillary), Oxygen saturation 87%. Her lips and soles looks blue, showing signs and symptoms of cyanosis. Her skin looks pallor and she has poor skin turgor.
Later, the ER physician ordered a chest x-ray that revealed three old rib fractures with the evidence of healing and one new hairline rib fracture on her right upper chest. The team suspected the child abuse and called Child Protective Services. The child is now transferred to the pediatric inpatient unit placed on a 72-hour hold. The mother is not allowed to visit her child without supervision.
Upon further investigation by child protective services, it was revealed that it was an accidental trauma caused by the boyfriend. Last night, the boyfriend was arguing with Katrina to give C.K. in foster care as their relationship is getting affected due to the responsibility of a child. Because of that, they both started fighting and in the heat of moment, the boyfriend caused the harm to the child as he was holding C.K. at that time, by squeezing her into his arms which caused the hairline fracture. Further Katrina requested the services to help her and resolve this issue. She said that, “this was not the first time her boyfriend fought over this topic and caused harm to C.K.”.
Nursing Diagnosis: Ineffective breathing pattern related to musculoskeletal impairment (rib fracture) as evidenced by dyspnea, abnormal breathing pattern, presence of adventitious breath sounds (wheezes), cyanosis, tachycardia (Doenges, Moorhouse, ; Murr, 2016, p.98).
Goal: The patient will have a patent airway and effective breathing pattern as evidenced by eupnea, clear breath sounds without wheezes, SpO2 98-100% (as per baseline data) and normal skin color within next 4 hours.
Assess the child for any pain/ discomfort, vital signs, cardiac rhythm, breath sounds, oxygen saturation, level of consciousness and other neurological changes (such as muscle weakness, seizures etc.) (Doenges et al., 2016, p.100, 359-360).
Administer prescribed respiratory medications, analgesics and oxygen at the lowest concentration indicated (Doenges et al., 2016, p.100).
Monitor continuous oxygen saturation, auscultate breath sounds, assess air movement and vital signs every 15 minutes.
Reinforce the need for adequate rest, while encouraging tolerable activity and maintain a calm environment while talking in front of the infant (Perry, Hockenberry, Lowdermilk, ; Wilson, 2017, p.1337).
Nurse should be aware about the importance of nutrition and proper techniques of feeding for C.K (For example: if feeding by bottle, the infant should be placed in possible upright position, bottle should be held at a more horizontal angle) (Doenges et al., 2016, p.362).
Because all vitals including pain are impacted by changes in oxygenation, and a decreased level of consciousness and severe pain can be responsible factors of impaired oxygenation and respiratory distress (Doenges et al., 2016, p.100, 359-360).
For the management of ineffective breathing pattern, cyanosis and tachycardia (Doenges et al., 2016, p.100).
To know the effectiveness of the treatment and current status of C.K in order to maintain the airway clear and effective breathing pattern (Doenges et al., 2016, p.22).
To decrease respiratory efforts by reducing the emotional distress (Anxiety, fear) of the child and improve quality of life (Perry et al., 2017, p. 971).
It helps in preventing aspiration (Perry et al., 2017, p.752), improving stamina and reducing the work of breathing (Doenges et al., 2016, p.362).
Evaluation: Goal has been met fully. After 4 hours of nursing interventions, C.K has clear airway and normal breathing pattern as evidenced by absence of wheezes, no signs of respiratory distress, SpO2 was 100% (normal as per patient’s baseline data), her lips, soles and mucous membranes were moist and pink, normal skin turgor (<2sec) was observed on assessment. Will continue to monitor to avoid the future respiratory dsyfunctioning.
Nursing Diagnosis: Acute pain related to physical injury agent (trauma) as evidenced by facial expressions of pain (grimace), expressive behavior (crying, irritability, fussiness), changes in physiological parameter (increased blood pressure, increased heart rate, increased respiratory rate, decreased oxygen saturation) (Doenges et al., 2016, p.600).
Goal: The patient will display relaxed manner (such as she will look calm and comfortable without any distress or pain while touching or assessing her). Patient will also show improved well-being such as baseline levels for blood pressure, pulse, temperature and respirations within next 4 hours.
Assess the level of pain using FLACC (Face, Legs, Activity, Cry, and Consolability) pain scale before and after administering the analgesics (Perry et al., 2017, p. 960).
Administer analgesic as ordered by doctor (opioids or non-opioids analgesics) (Swearingen, 2016, p. 606).
Implement nonpharmacological methods for pain relief as per the developmental age of child. For example- hot or cold compressions, comfortable positioning in bed and gentle massage on foot (Swearingen, 2016, p. 606).
Record the changes in vital signs (temperature, heart rate, respirations and blood pressure) after the treatment. Also, after 30 minutes of administering the medication, reassess the level of pain using FLACC pain scale and asses the side effects of medication (for example- respiratory distress, dry mouth) (Swearingen, 2016, p. 42).
Maintain a quite environment while giving care to child. Do not shake the baby. Make sure she is clean and comfortable. Encourage long periods of rest (Swearingen, 2016, p. 586-587). The assessment of pain using pain scale helps to determine the degree of pain, selection of pain management treatment and note the effectiveness or ineffectiveness of pain treatments (Perry et al., 2017, p. 959).
Analgesics are used to control pain (Perry et al., 2017, p. 971).
Nonpharmacological methods complement the pharmacological methods for pain relief (Swearingen, 2016, p. 606).
To note the effectiveness and ineffectiveness of pain management treatments (Perry et al., 2017, p. 959).
Shaking the baby while providing care could cause more damage (Swearingen, 2016, p. 587). Also, rest and sleep helps to decrease the level of pain (Swearingen, 2016, p. 44).
Evaluation: After 4 hours of pain management treatment, patient looks comfortable and relaxed in bed as evidenced by she has started to engage in play activities without showing any signs of distress. Vitals are stable per its baseline levels. HR- 90 bpm, BP- 100/60, RR-34 breaths per minute and T- 36.7 degrees Celsius. Infant does not look irritable and fussy while performing assessment. No side effects of pain medications noted (such as respiratory distress, dry mouth).
Nursing Diagnosis: Ineffective childbearing process related to unwanted pregnancy, insufficient support systems (such as no financial support) as evidenced by insufficient access of support system, unsafe environment for an infant, insufficient attachment behavior (father) (Doenges et al., 2016, p.116).
Goal: The mother will demonstrate behavior or lifestyle changes to cope with or resolve problematic factors as evidenced by Katrina will take care of her child by herself, she will seek help from available community support systems (such as, she will take the advantage of day care centers while she is working to eliminate the financial crisis instead of leaving her child with her boyfriend because he is not confident and ready to take care/responsibility of child), she will learn the appropriate parenthood role by attending parenting classes in order to maintain effective childbearing process within 48 hours after getting C.K’s custody.
Discuss the available community support groups/parenting class such as childcare services, respite house, day care centers, baby sitters, nursing homes etc. (Doenges et al., 2016, p.117, 624).
Use nonjudgmental and nonthreatening way while connecting with child’s mother (Doenges et al., 2016, p.624).
Establish rapport with mother and allow free expression of feelings, including frustration, anger, hostility, and hopelessness (Doenges et al., 2016, p.122).
Home-visit is necessary within 48-72 hours. Appreciate Katrina for showing any competent parenting skill (Such as- good nutritional status of her child, C. K’s attachment with her mother and no further injury/complication observed) (Perry et al., 2017, p.855).
Encourage and help her to develop self-centered support systems appropriate to a condition such as music, social-work, friends and assist her in time management and enhance positivity (Doenges et al., 2016, p.624). This will increase the mother’s knowledge about parenting skills and child development, also provides a supportive atmosphere while incorporating in a new role (Doenges et al., 2016, p.117, 624).
Because Negative attitude is inimical to positive consequences (Doenges et al., 2016, p.624). “The child is more likely to be helped if the mother will trust the staff. If she feels alienated by the staff, she may deny the child assess to care” (Swearingen, 2016, p.584).
This promotes a therapeutic relationship and support for problem-solving solutions and minimize the risk of violent behavior (Doenges et al., 2016, p.122).
To prevent the further child maltreatment (if still happening), notify the mother about normal child growth, proper parenting, solve the still existing problems. Praising her on showing positive outcomes, will promote her sense of parental adequacy and will enhance her self-esteem. (Perry et al., 2017, p.855).
It helps to cope with difficult situations more positively and effectively (Doenges et al., 2016, p.624).
Evaluation: After 48 hours of nursing interventions, upon the home visit, Katrina revealed that she is living by herself now. She said that, “I realized my child is my life, nothing else is important for me”. She showed a proper diet chart for C. K. She said that her life is much better now as she arranged a day care center for her child and she can earn more money to support her child’s proper growth and development without any stress/fear. She was so excited to tell all these things. She even showed her present weekly timetable which includes C. K’s routine health care check-up appointments. The little angel, C.K was also looking happy, healthier than before and was busy in playing.
Concept of Caring
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. (14th ed.). Philadelphia: F.A. Davis Company.
Potter, P., Perry, A., Stockert, P., Hall, A. (2014). Canadian Fundamentals of Nursing (5th ed.). Toronto, ON: Elsevier Canada.
Perry, S., Hockenberry, M., Lowdermilk, D. ; Wilson, D. (2017). Maternal Child Nursing Care in Canada (2nd Ed). Toronto, Ontario: Elsevier Canada.
Swearingen, P. (Ed.). (2016). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, and psychiatric-mental health (4th ed.). St. Louis, Missouri: Elsevier.