Question

An 8-year-old boy is seen in the emergency department accompanied by his parents, maternal grandparents, and two younger siblings aged 2 and 5, and his mother’s sister.

Subjective Data

• Multiple people are speaking at once, some in English and others in Spanish.

• The father, in a Spanish accent, tells the nurse, “My son, he fell down. Es en mucho dolor.”

• A certified medical interpreter is at the child’s bedside.

• In Spanish, the child communicates that he fell when riding his bicycle and has injured his right leg. He rates his pain at 5 out of 10 on a numeric pain scale.

• When queried about his immunization history, neither the child nor any of the adults know when or if the child has received his immunizations.

Objective Data

• Abrasion and bruise, 2 in. by 2 in. in size, noted on outer aspect of right leg distal to the knee

• Abrasion is dirt covered

• X-rays performed—no fracture seen

Vital Signs:

• Temperature: 98.6°F
• Heart rate: 90 bpm
• Respiratory rate: 24 rpm
• Blood pressure: 100/60 mm Hg

Health-Care Provider’s Orders

• Administer ibuprofen 200 mg PO every 6 hr for pain

• Cleanse wound with soap and water

• Apply triple antibiotic (bacitracin/neomycin/ polymyxin B) ointment after cleansing

• Administer Tdap (Tetanus, Diphtheria, Pertussis) vaccine IM STAT

• Educate child and parents regarding need for helmet protection when riding bicycle

• Refer to pediatric clinic for follow-up

CASE SCENARIO QUESTIONS

A. What subjective assessments indicate that the client is experiencing a health alteration?

1.

2.

3.

B. What objective assessments indicate that the client is experiencing a health alteration?

1.

2.

3.

4.

C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?

1.

D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?

1.

2.

3.

4.

F. What physiological characteristics should the child exhibit after treatment?

1.

G. What psychological characteristics should the child and family exhibit before being discharged home?

1.

Nursing (pediatric)

Answer 1

A) subjective data indicates health alterations.

1. Pain score of 5 over 10
2. The immunization history of the child is not known by the adults present, neither has any immunization record.
3. No protective measures taken during riding a bicycle.

B) Objective data indicating health alteration.

1. Abrasion and bruise present on the rihjt knee.
2. Abrasion is 2x2 size with dirt covered
3. NO fracture as per the xray

C) Skin abrasion relate to the history of fall from the bicycle.

D) The Interventon are

1. Pain medication to be given as advised.
2. Cleaning of the wound with soap and water
3. Applying of medication on the wound
4. Eduation regarding the safety practices during riding a bicycle
5. Importance of immunization. Educate the parents to bring the immunization recirds whenever they visit any clinics.
6. Educate to keep the wound clean and dry for faster healing
7. Less outdoor activities till the wound is healed.
8. Consult a peadiatrician for further follow up

E) Outcomes

1. Lesser pain verbalised by the child
2. Better movement of his right leg
3. Verbalised that he understood the safety precautions used during riding the bicycle.

F) Psychological charecteristics after treatment

The child may experience fera and anxiety after the treatment.

G) The psychological characteristics of child and parents on discharge

Anxious and fear of parents to allow their child to go for riding cycle again

Initial fear for the child to ride the bicycle again due to the fear of falling again.