UNIT 7: CASE STUDY 7B [Care of the Injured Child (Abuse and Note that the course pack

provided to you in any form

Violence in the Family)] is intended only for the use
in connection with the
course that you are enrolled
CASE STUDY: A CHILD WHO HAS BEEN ABUSED in. It is not for distribution
or sale. Permission should
be obtained from your
Dany is a 2-year-old brought to the emergency room by his mother instructor for any use other
than for what it is intended.
and her boyfriend.

CHIEF CONCERN:
“He fell and burnt his hand on the stove.”

HISTORY OF CHIEF CONCERN:

Mother was watching child earlier in the day when child “tripped on a throw rug.” As he reached
out a hand to stop his fall, he put it into a gas flame on top of the stove. Posterior side of hand
has a blackened denuded extremely painful area 4 cm x 4 cm. Forehead and left arm are
ecchymotic.

FAMILY PROFILE:
Mother is a 24-year-old single parent; works part time as a city bus driver. Boyfriend is not the
father of David; he works as a hospital orderly; has lived with the family for 6 months. Boyfriend
and mother share an apartment over a neighborhood delicatessen. Mother states, “Our
neighborhood is falling to pieces; a pedophile has moved into the next block.” Father is the one
who insisted that child be examined. Mother states, “Don’t think I caused this. I’m not a bad
parent like my mother.”

HISTORY OF PAST ILLNESSES:

Had “colic and crying” for almost all of first year. Child seen in emergency room at 8 months for
a possible head injury and retinal hemorrhages from a fall from an infant walker. Seen 3 months
ago for fall down a flight of apartment stairs. Health maintenance by well-child conference has
been sporadic. Mother unsure how many immunizations child has received; states it is too
difficult to get him dressed to take out.

PREGNANCY HISTORY:
Pregnancy was the result of “date rape.” Mother had heartburn all through pregnancy. Gained
70 pounds and lost none of the weight afterwards. States “he ruined my figure for life.” No falls
or radiographs during pregnancy. Mother continued to smoke and continued “drinking beers on
Saturday night.” Smoked marijuana “occasionally.” Unsure whether she used cocaine during
pregnancy. “May have used it once” after pregnancy confirmation. Birth weight was
“three-something.” Length: unknown. Apgars: unknown. Child hospitalized for 3 weeks in a
neonatal care unit.

DAY HISTORY:
Nutrition: Eats table food; mother does not prepare anything special for him.
Sleep: “Poor sleeper; always awake and crying.”
Play/recreations: Child has a blanket he “always carries.”
Growth and Development: Mother unable to remember milestones; child presently walks well;
is not toilet trained. Mother not certain if he speaks in sentences; boyfriend is sure he does. Is
able to feed self; boyfriend describes him as a “cute kid.” Mother describes him as a “bratty kid.”
REVIEW OF SYSTEMS:
Head: Had “lumpy scaly” scalp condition as infant. “Looked like he had lizard skin.” Treated with
mineral oil and crusts disappeared.
Ears: Otitis media x 3; mother states he doesn't come when she calls him; “if he's not deaf, he
acts like it.”
Eyes: No infections; mother feels he sees all right.
Nose: Had bleeding nose from a fall earlier in this day. Enough that he “ruined” mother's blouse
with blood.
Mouth: A lot of fussiness with teething as an infant. Mother gave him whiskey to keep him from
crying and keeping her awake.
Genitalia: Persistent diaper rashes. Not toilet trained yet.

PHYSICAL EXAMINATION:
Weight: 23 pounds (4th percentile). Height: 31.5 inches (12th percentile).
General Appearance: Rangy looking, crying, distressed 2-year-old. Blackened 4 x 4 cm area
present on dorsum of right hand; ecchymotic area present around eyes and on forehead.
Head: Normocephalic; fontanelles closed; one 3 x 3 space over right parietal area where hair is
missing. Scalp erythematous at area. no scaling present. Large 3 x 5 cm dark ecchymotic area
with underlying edema on center of forehead. Ecchymotic area extends to surround both eye
globes. An older yellow-green fading ecchymotic area is on left temple.
Eyes: Red reflex; follows to all fields of vision. Small subconjunctival hemorrhage in left sclera.
Vision not formally tested but child reaches for object presented to him.
Ears: TMs pink, landmarks present; dark brown cerumen in right external canal. Hearing not
tested, but child follows instructions as if he has normal conversation level hearing. Difficult to
evaluate language as child is in pain and crying.
Nose: Nares patent; midline septum.
Mouth: 20 deciduous teeth; no cavities; midline uvula; gag reflex intact, membrane moist.
Neck: Midline trachea; 1 palpable lymph node in anterior left cervical chain. Full range of
motion.
Lungs: Respiratory rate: 24 breaths per minute (crying). Rhonchi in upper lobes.
Heart: Rate: 120 beats per minute; no murmurs.
Abdomen: Liver and spleen both palpable 1 cm below costal margins; ecchymotic area
(purple-red) 4 x 3 cm present over left midabdomen; no masses palpable. Tenderness elicited at
ecchymotic site.
Genito-rectal: Circumcised male; testes descended. Midline meatus. Reddened, irritated area in
diaper area; skin covered with caked feces.
Extremities: Full range of motion; pain elicited on movement of left elbow; joint slightly
reddened and swollen. Four fading ecchymotic areas on legs (green-yellow). Blackened 4 x 4 cm
area with white central area surrounded by erythema and blisters on dorsum of right hand.
Painful to touch. Ten scattered circular scabs (½ cm diameter) on upper arms. Reddened circular
lesions on posterior legs.
Neuro: Patellar reflex 2+. Sensory and motor nerves grossly intact.

Dany is suspected as being victim of child abuse.

CASE STUDY QUESTIONS:

INSTRUCTION: Select the best answer. For every answer that you choose, write, or indicate the
rationale. You will earn 2 points for every item you answered correctly. Do not forget to include
your references here.

1. Dany’s mother reported that he fell and burned the back of his hand when he reached
across the stove to break his fall. What would make you suspect that this is abuse and not
an accident?
a. The mother readily recounts the history.
b. Broken bones are always found with abuse.
c. The history is inconsistent with the injury.
d. A gas flame isn’t hot enough to burn.
Answer:
______________________________________________________________________________
______________________________________________________________________________

2. What is a factor in Dany’s history that makes him high risk for abuse?
a. He was named for his maternal grandfather.
b. He was hospitalized at birth for prematurity.
c. He is male and attends a preschool program.
d. He learned to walk at 12 months of age.
Answer:
______________________________________________________________________________
______________________________________________________________________________

3. Cigarette burns resemble the scabs of impetigo, a streptococci infection. What is one way to
differentiate between these two?
a. Impetigo lesions always occur on the face.
b. Cigarette burns turn green before they fade.
c. Impetigo lesions occur only in summer.
d. Cigarette burns heal with a circular scar.
Answer:
______________________________________________________________________________
______________________________________________________________________________

4. Which finding in Dany’s health history would make you suspect he might have been beaten
by an electric cord?
a. He has circular lesions on his legs.
b. You notice small petechiae on his back.
c. He states that he hates electricity.
d. He won’t talk about his accident.
Answer:
______________________________________________________________________________
______________________________________________________________________________
5. Dany may have been a victim of a shaken baby syndrome. Which finding in his history best
suggests this?
a. Difficulty currently bending his elbow
b. Retinal hemorrhages at 8 months
c. History of colic for first 3 months
d. Circular lesions on his posterior legs
Answer:
______________________________________________________________________________
______________________________________________________________________________

6. Dany’s mother states he has not had any immunizations because getting him dressed to take
him for appointments was too difficult. Her actions can be categorized as:
a. physical abuse.
b. Munchausen abuse.
c. child neglect.
d. psychological abuse.
Answer:
______________________________________________________________________________
______________________________________________________________________________

7. The Munchausen by proxy syndrome refers to a:

a. parent who shows little interest in children.
b. child who pretends to be ill when actually well.
c. parent who causes a child to have disease symptoms.
d. parent who does not understand normal child development.
Answer:
______________________________________________________________________________
______________________________________________________________________________

8. Although it might mean nothing, which statement by Dany would make you wonder if a role
reversal between him and his mother has occurred?
a. “Everything will be all right, Mom.”
b. “I can’t breathe. It hurts too much.”
c. “I promise not to play by the stove again.”
d. “I want to go home. I hate it here.”
Answer:
______________________________________________________________________________
______________________________________________________________________________

9. What is a finding usually present with Munchausen by proxy syndrome?

a. The child is usually female and older than 5 years of age.
b. Although the child is bleeding, he doesn’t seem to have pain.
c. The child never cries even though you know he is in pain.
d. The child’s symptoms occur when the parent is present.
Answer:
______________________________________________________________________________
______________________________________________________________________________
10. Dany is diagnosed as having failure to thrive. This is based on what finding in his health
history?
a. His mother says he is a picky eater.
b. His weight is under the 5th percentile.
c. He only talks in two-word sentences.
d. He has had two infections in the past year.
Answer:
______________________________________________________________________________
______________________________________________________________________________

11. An infant with failure to thrive often shows which marked characteristic?
a. Unusual torso accumulation of fat
b. Staring intensely at caregivers
c. Advanced psychosocial milestones
d. Angry, forceful, persistent crying
Answer:
______________________________________________________________________________
______________________________________________________________________________

12. What is a prime nursing responsibility for a hospitalized infant with failure to thrive?
a. Arrange for a primary care provider
b. Expose the child to many individuals
c. Limit the dietary intake to soft foods
d. Do not allow the child’s parents to visit
Answer:
______________________________________________________________________________
______________________________________________________________________________

13. Dany’s mother tells you that she was raped. Sexual abuse or rape occurs most frequently at
what age?
a. Women ages 30 to 35
b. School-aged children
c. Adolescents
d. Women ages 20 to 29
Answer:
______________________________________________________________________________
______________________________________________________________________________

14. Dany’s mother tells you that a pedophile lives in her neighborhood. His mother most likely
knows this because:
a. grade schools are required to post photos of child offenders.
b. sexual offenders must personally tell neighbors who they are.
c. police must alert citizens if a sexual offender lives near them.
d. sexual offenders’ names are published yearly in newspapers.
Answer:
______________________________________________________________________________
______________________________________________________________________________
15. If a sex offender is a pedophile, this means he:
a. distributes elicit pornographic literature.
b. has been accused and convicted of assault.
c. talks to grade-school children outside schools.
d. is an adult who uses children for sexual gratification.
Answer:
______________________________________________________________________________
______________________________________________________________________________

16. The term “date rape” refers to:

a. rape that occurs in the early evening.
b. rape that occurs among friends.
c. assault that occurs after alcohol ingestion.
d. sexual assault in a college-aged student.
Answer:
______________________________________________________________________________
______________________________________________________________________________

17. The date rape drug flunitrazepam (Rohypnol) has what unfortunate effect?
a. It causes severe headache the next morning.
b. It is fatal if mixed with two types of alcohol.
c. It causes a rapid increase in digestion.
d. It causes a loss of memory for recent events.
Answer:
______________________________________________________________________________
______________________________________________________________________________

18. An adolescent phone an emergency room and says she has been raped. Which action below
would be your best action?
a. Discourage her from recounting the event to help reduce her stress.
b. Tell her to immediately take a bath to help prevent pregnancy.
c. Urge her to come into the emergency room for care and counseling.
d. Tell her to throw away soiled clothes to not remind her of the event.
Answer:
______________________________________________________________________________
______________________________________________________________________________

19. Which of the following findings makes Dany’s mother high risk for being an abuser?
a. She was abused herself as a child.
b. She is over 21 and a single parent.
c. She works part time as a bus driver.
d. She has only a high school education.
Answer:
______________________________________________________________________________
______________________________________________________________________________
20. You want to explore if Dany’s mother is a victim of intimate partner abuse. Which statement
by her is a common reason that victims do not report this type of abuse?
a. “We’re saving money to buy a new house.”
b. “I don’t deserve to be treated any better.”
c. “We’re a lower-level economic family.”
d. “I wish I had more time to spend by myself.”
Answer:
______________________________________________________________________________
______________________________________________________________________________

Adapted from:
Pillitteri, A. (2010). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family (6th Edition). Lippincott Williams & Williams.

REMINDER:

 Once done, save your output following the format below as the filename:
Case_Study_7B_LAST NAME_FIRST NAME(initial)_HS103
Example: Case_Study_7B_DELACRUZ_J._HS103

 Submit this requirement by uploading this file on Canvas or via my email address at
ggpillero@up.edu.ph on or before: September 17, 2021.