Summary of Case
Injury resulting from trauma is one of the most complicated nursing issues, which requires immediate and collaborative action to save human lives. Indeed, trauma is one of the leading causes of death in the United States for individuals younger than 44 years (Urden et al., 2016). Moreover, multi-trauma is a severe condition characterized by impairments in several bodily systems. Such traumas necessitate detailed and multifaceted diagnosis and treatment to ensure compatible management of the condition for the most beneficial outcomes for the patient. This case study addresses a multi-trauma in a seven-year-old child who has been in a multi-car motor vehicle crash (MVC). The emergency team’s report informs the analysis of the multi-trauma case by providing the information necessary for establishing the assessment of the patient, diagnosis, and plan of care.
Components of Critical Thinking
Assumptions
Reviewing the initial reports on the pediatric patient’s assessment provides a basis for nursing assumptions as per the severity of the condition and the complications of the patient’s multi-trauma. The accuracy of assumptions is a significant step in proper diagnosis and treatment, which should be validated by objective evidence-based data in the later stages of patient assessment. As informed by the initial report, the child has received multiple injuries to the head, which is demonstrated by the bruises on the forehead, neck, and the left side of the face. Moreover, the report states that the patient was unconscious upon the emergency team’s arrival. This information implies a head injury, including a concussion or brain damage.
Moreover, the immobilized left leg and C-spine might indicate a fraction of bones, which should be diagnosed upon admission to the hospital. Furthermore, the change in the vital signs of the patient between the report from the car crash scene and the nursing assessment indicates a lowering of temperature (from 97.4 ax to 96.5 ax), a decrease in blood pressure level (from 100/64 to 98/66), and the decrease of oxygen saturation (from 91% on 10L O2 to 90% on 10L O2). Consequently, an assumption might be made that lowering oxygen level might indicate respiratory system impairment, which requires proper diagnosis.
In addition, lowering body temperature and blood pressure might contribute to the diminished distribution of blood to the vital organs, which requires immediate action. However, the nursing assessment details indicate a score of GCS 13, which is an indicator of a mild head injury; the results of a CT scan of the head and spine were negative (Urden et al., 2016). Such information allows for prioritizing the lower extremities and the potential for internal bleeding and traumatic impact on vital organs. Indeed, the swelling of the left flank and closed deformity to the left femur indicate multiple traumas to the left side of the patient’s body. Most significantly, gross hematuria and the swelling on the left flank might indicate kidney injury, which should be addressed timely and properly to avoid complications.
Data Inconsistencies
Given the information retrieved from the reports, some data inconsistencies should be clarified. Firstly, the patient’s age is unclear since the initial statement indicates a 5-year-old pediatric patient, while the report of the emergency team indicates a 7-year-old patient. Overall, the inconsistency in the vital signs reported is validated by the change in the patient’s condition with time. However, monitoring vital signs throughout the patient’s diagnosis and treatment processes is essential.
Data Clusters
Neurological System. The data obtained during the pediatric patient assessment indicate the following characteristics of the neurological system. Firstly, the patient was discovered unconscious on the site of the car crash event; the child regained consciousness en route. The patient’s responsiveness is complicated by the nervous state characterized by screaming and crying; the patient is non-cooperative. PERRLA; he vital signs assessment includes the body’s temperature is 96.5 ax, the patient’s pulse at a rate of 126, respiratory rate is 26, blood pressure is 98/66, and O2 saturation is 90% on 10L O2. Forehead, neck, and facial bruises, lacerations, and swelling are identified; brain injury is classified as GCS – 13.
Respiratory System. The data demonstrating the indicators of the respiratory system is presented by the information typically obtained during the ABCDE assessment concentrating on airway assessment and breathing (Lecturio Medical, 2018). According to the report, the pediatric patient’s breath is equal and clear in sound.
Cardiac System. The examination of the heart indicates normal tones with regular rhythms and no signs of murmur.
Gastrointestinal System. The patient’s abdomen is firm and flat; bruises and swelling of the left flank; bowel sounds are diminished.
Genitourinary System. The assessment of the patient unveiled evident bruising of the left flank and gross hematuria.
Skin and Musculoskeletal. The patient’s left leg is immobilized in a traction splint; the foot of the left leg is cool and pale with +1 left dorsalis pedis pulse. Skin is cool and wet because of the rain; the turgor is good. The site of intravenous infusion is not swollen and not red.
Psychosocial. The child is calling for her mother, who is in a severe condition, traumatized by the car crash. The patient is in emotional distress, crying, and reluctance to cooperate with the health care workers. Her father and grandmother are at the hospital, ready to support her.
Missing Data
The reports do not contain any information about the patient’s health history. Moreover, the immunization and allergy data are missing, which might complicate the process of administering the treatment and medications. The report does not address the presence of a fraction of bones in the leg. Overall, the results of the tests are likely to inform healthcare decision-makers about the appropriate means of tackling the patient’s condition.
Conclusions
The discussed data clusters presented for each body system provide a detailed and comprehensive picture of the patient’s condition and the necessary diagnoses and treatment steps. Despite the clarity of the available data, the contradictions in the indicators of vital signs and the missing data complicate the conclusions due to the evident presence of multi-trauma in pediatric patients. In particular, the head injury and brain trauma are signaled by bruises and swelling; however, the CT and assessment indicate mild brain injury. Such indicators suggest observing the patient’s brain function over time to eliminate the risk of complications. However, the prioritized issues are the closed deformity to the left femur and the swelling of the left flank with the presence of gross hematuria. These data indicate musculoskeletal injury of the left leg and kidney injury. It is essential to identify the characteristics of these pathophysiological processes and determine diagnostic tests and the nursing plan of care.
Most Significant Pathophysiological Process
Etiology
The most significant pathophysiological processes are acute kidney injury and femoral deformity of the left leg. The etiology of kidney injury is the blunt trauma of the left flank, which is signified by bruising and swelling of the left side of the body (Urden et al., 2016). The etiology of the femoral deformity is the blunt trauma of the leg, which indicates a closed deformity of the thigh bone.
Pathology
The pathology of kidney injury is associated with the impairment of kidney function. It is associated with a “decline in glomerular filtration rate (GFR), with subsequent retention of products in the blood that is normally excreted by the kidneys; this disrupts electrolyte balance, acid–base homeostasis, and fluid volume equilibrium” (Urden et al., 2016, p. 742). The evidence for this pathophysiological process is gross hematuria and the left flunk’s swelling and bruising. In addition, the pathology of closed femoral deformity or fracture is the skin being intact while the bone is deformed, causing the patient disability and pain.
Clinical Manifestations
The clinical manifestations of closed deformity of the left femur are the inability to walk, severe pain, and swelling. The patient’s leg is immobile, and the bruises, swelling, and evidently visible deformity indicate these manifestations. As for acute kidney injury, its clinical manifestations include a change in serum creatinine, swelling, and gross hematuria (Urden et al., 2016). The diagnosis of these issues should be prioritized due to the evidence presented in the reports signalizing the presence of such pathophysiological processes.
Diagnostic Tests
The femur fracture is diagnosed via x-ray examination to identify the fracture’s severity, location, and scope. As for kidney injury, it should be tested via multiple approaches, given the complexity of the condition and the organ function. In particular, CT of the kidney and other gastrointestinal system organs should be conducted. Moreover, blood tests and urine tests should be performed to identify the level of serum creatinine, electrolytes, and blood in urine, which commonly signalize the disruption of kidney function.
The rationale for Abnormal Data
Lab data is considered abnormal when its indicators do not match the conventional norm for a healthy individual. In particular, creatinine levels higher than 1.2 and blood urea nitrogen should not exceed 20 (Urden et al., 2016). Abnormal indicators signify the failure of proper kidney function to eliminate waste from the patient’s blood. As for the leg fracture, the image assessment showing deforming of bone is considered abnormal.
Nursing Plan of Care
Clinical Practice Guidelines
The clinical practice guidelines for kidney injury interventions proposed in the case are based on the standard procedures. In particular, as stated by Urden et al. (2016), it is essential to conduct immediate CT and blood tests in the case of acute kidney injury. Moreover, immobilizing the fractured extremities is a conventional clinical practice guideline. Cardiologic, respiratory, and gastroenterological monitoring and consultations are necessary to control the development of the multi traumatic condition concerning other body systems.
Evaluation of Medical Therapy
The rationale for Medical Orders
The rationale for the medications presented in the chart is validated by the spectrum of symptoms experienced by the patient. Pain relief and electrolyte normalization are essential for blunt injuries (Urden et al., 2016). Moreover, the prescription of Furosemide is validated by the evidence suggesting positive outcomes for pediatric patients with kidney injury (Sethi et al., 2021).
Medications
Identification of Questionable Orders
It is questionable whether the patient needs more severe kidney medications to regulate renal function; it might be necessary to clarify the test results and observe the patient determine consecutive treatment decisions.
Legal / Ethical Issues
The presented case of the pediatric patient is characterized by some ethical and legal considerations. One of the issues in the case is the legality and ethicality of the treatment of the child without parents present. Indeed, the healthcare professionals administering the diagnosis and treatment should act in accordance with the policies and protocols for critical care in the cases of multiple traumas. However, the information about the child’s condition should be delivered to the family in a timely manner to ensure their awareness and possible decision-making. Since the patient’s mother is in critical condition, it is the father, who is regarded as a caregiver of the child and should be informed about the patient’s condition. From the ethical perspective, it is contradictory how to approach the child for cooperation in treatment under the circumstances when she calls her mother and is in distress.
The stakeholders involved in these issues are the patient, the family members, and the healthcare workers. The patient’s primary interest is the obtainment of proper treatment and pain relief and anxiety elimination. This goal might be achieved by allowing a family member (father or grandmother) to be present during resuscitation. The family members’ involvement in the issues is stemmed from the desire to support the child and ensure the appropriateness and adequacy of care. Health care workers’ involvement in the issues is validated by the necessity to administer urgent measures without distractions for timely addressing of the life-threatening conditions in the patient.
The decisions that a nurse should make to resolve the issues should be based on hospital policies and protocols. The vitally important procedures should be prioritized to ensure the patient’s safety. After that, the trained staff working with families should discuss the patient’s condition and the opportunities for family presence with the father and the grandmother (Toronto & LaRocco, 2019). The interests and well-being of the patient, who is a child, should be prioritized when handling this issue. Therefore, it is important for the nurse to allow the child to be with her father during the medical procedures.
Family Presence
Family presence during resuscitation procedures has long been a disputable issue addressed by individual healthcare professionals and medical organizations. In particular, the core of the argument is based on the ambiguity of family members’ presence during the medical procedures of resuscitation. On the one hand, such a presence might be beneficial for the patient’s well-being and recovery (Providence Health Vancouver, 2016). On the other hand, the management of family members’ presence and emotional state might obstruct the staff’s performance of the medical procedures. However, one might claim that it is necessary to allow family members to be present and witness resuscitation procedures performed for their loved ones due to the transparency and inclusion granted by such an approach.
From a legal perspective, the procedures for regulating family members’ presence should be in place. According to Toronto and LaRocco (2019), such efforts should be regulated by specifically designed hospital programs overseen and monitored by medical organizations. For that matter, the Emergency Nurses Association’s (ENA) Presenting the Option for Family Presence (1995) offers educational guidelines on hospitals’ regulation of family presence (Toronto & LaRocco, 2019). Thus, with proper legal issues addressed and trained and educated staff, hospitals might implement family presence during resuscitation without hindering the effectiveness of the procedures. From an ethical point of view, allowing the family to witness a patient’s resuscitation might be rather contradictory and depends on the desire of the family and the patient (Providence Health Vancouver, 2016). Nonetheless, if the patient expresses willingness to have their family present, it is important to provide them with such an opportunity.
There are significant benefits to having families present during the resuscitation procedures. They are mostly related to the spirituality and psychological wellness of the patients experiencing their families’ support (Providence Health Vancouver, 2016; Toronto & LaRocco, 2019). Indeed, research suggests that family-centered care provides benefits for patients due to the availability of loved ones’ support (Providence Health Vancouver, 2016; Urden et al., 2016). Moreover, “the experience of being present throughout the resuscitation efforts allowed the family member to have a sense that they had provided comfort to the patient during the traumatic event” (Toronto & LaRocco, 2019, p. 43). On the other hand, there are risks associated with a family presence that include adverse outcomes for patients, healthcare workers, and family members. Firstly, not all patients are determined to have their family members as witnesses, which might hinder their recovery if they feel uncomfortable. Secondly, healthcare workers’ performance might be obstructed in the case of family members’ inadequate behavior. Finally, the family members witnessing the resuscitation procedures performed for their loved ones might be emotionally traumatized.
Educational and organizational efforts should be implemented to establish a written policy in the health care institution to regulate family presence during resuscitation. First, it is necessary to identify the predetermining factors facilitating the need for the new policy, which will inform the goals of the new document. Second, the objectives should be outlined, and the appropriate legal provisions on a federal and state level should be consulted. Third, medical organizations’ positions on the issue of family presence should be analyzed and incorporated (Toronto & LaRocco, 2019). Finally, the policy should be created, assessed, and implemented via training of the staff and actual application to practice.
References
Lecturio Medical. (2018). Trauma: Primary survey, ABCDE-assessments & take-home points – emergency medicine [Video]. YouTube. Web.
Providence Health Vancouver. (2016). Family presence: Patient & family-centered care at PHC [Video]. YouTube. Web.
Sethi, S. K., Bunchman, T., Chakraborty, R., & Raina, R. (2021). Pediatric acute kidney injury: New advances in the last decade. Kidney Research and Clinical Practice, 40(1), 40.
Toronto, C. E., & LaRocco, S. A. (2019). Family perception of and experience with family presence during cardiopulmonary resuscitation: An integrative review. Journal of clinical nursing, 28(1-2), 32-46.
Urden, L. D., Stacy, K. M. & Lough, M. E. (2016). Priorities in critical care nursing (8th ed.). Elsevier.