NURSING GRAND ROUNDS PRESENTED BY

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NURSING GRAND ROUNDSPRESENTED BY

• Alison Vallance
• Natalie Law
• The Paediatric Unit
• Maitland Hospital

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Non- accidental InjuryMeningococcal Meningitis

• Good observation skills.
• Accurate documentation.
• Relevance of procedures and protocols.

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Non- accidental Injury

• What constitutes abuse?
• General and specific indicators for abuse.
• Health professionals response.

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Child abuse and neglect consists of an act of
commission or omission that endangers or impairs
a childs physical and or emotional development

• Physical Abuse
• Sexual Abuse
• Emotional or Psychological Abuse.
• Neglect.

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Physical Abuse

• Excessive discipline.
• Severe beatings.
• Shaking.
• Cigarette burns.
• Strangulations.
• Female genital mutilations.

• Bruising.
• Lacerations.
• Burns.
• Fractures or dislocations.
• Head injuries.
• Internal injuries.

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• History of previous harm.
• Social or geographical isolation.
• Abuse of neglect of sibling.
• Domestic violence.
• Substance abuse.
• Functional parenting deficiency.
• Behaviour management problems.
• Unrealistic expectations.

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General Indicators.

• Conflicting accounts of injury.
• Child discloses.
• Family or friend discloses suspected abuse.
• Poor concentration.
• Sleeping problems.
• Sudden behaviour changes.
• Unexplained illnesses, headaches etc.

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Specific Indicators in the Child

• Facial, head neck bruising.
• Welts or lacerations.
• Inconsistent explanation.
• Marks or bruising showing shape of object.
• Bite marks.
• Multiple injuries.
• Bruising of differing ages.
• Ingestion of poisons, alcohol other drugs.
• Fractures or dislocations under 3 years.
• Burns and scalds.
• Head injury in the non-mobile child.

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Specific Parental Indicators

• Direct admission.
• Family history of violence.
• Past history of own maltreatment.
• Repeated presentations.
• Marked delay.
• Inconsistent account of events or cause of injury.

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Response

• Under the Children and Young Persons (Care and
  Protection) Act.
• DoCS notification.
• Helpline 24/7
• Faxed report . Risk of Harm.
• Emergency Pager or 000.

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Annas Story

• 2 years.
• Referred to local hospital from Child health
  nurse.
• Night terrors.
• O/A at 4pm.
• Multiple facial bruising.
• Abrasions to abdomen, R thigh and arm.
• Obs stable.
• Wgt. (3rd Percentile) Ht. 75th .
• Reports thrashing, screaming and biting self.
• Referred to Maitland

• Arrived Maitland 1913.
• Alert, interactive.
• Paediatric review.
• Admitted for observation Paediatric Unit 2240hrs.
• Difficult to settle but uneventful night.
• Reviewed by Paediatrician in am.
• Abdominal bruises.
• Bruises to forehead.
• Inconsistent bite mark.
• Bruising L scapula.

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Social History

• Anna lives with mother and fiancé.
• Visits father 2 out of 3 weekends.
• Paternal Gparents overseas.
• Maternal Gparents interstate.
• Moved.
• No other siblings.
• Recently Anna wary of fiancé.

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• Discharged 4 days later into mothers care.
• Ophthalmology, head CT and bloods normal.
• Bone scan Increased uptake L scapula.
• Skeletal survey normal.
• No concerns re. growth.
• Discharge plan
• Review Maitland Paediatrician 2 weeks
• Home visit Child Protection Team.
• Community Health.

• Child Protection Team at JHCH notified.
• DoCS notification.
• Bloods.
• Cranial CT.
• Ophthalmology review.
• Transfer.

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2nd Presentation.

• 2 weeks later.
• O/A
• Nausea vomiting.
• Reluctant to move R arm or R leg.
• Facial bruising to L eye.
• Bloods unremarkable.
• Transferred to Maitland.

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Clinical Findings

• Pale and lethargic.
• Unable to lift arm.
• R leg abducted and shortened.
• Bruising to Knee.
• Facial bruising.
• Abrasions to mouth.
• NO history of trauma.
• NO explanation.
• NO recent visits.
• ENT and Abdo NAD.

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Radiological Findings

• R Humerus
• R Distal radius
• R proximal tibia.
• Admitted to Paed. Unit 0030hrs.
• IV fluids.
• Analgesia.
• Bed rest.
• Cares by Nursing Staff.
• DoCS notification in am.

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• Transferred to JHCH next day.
• Bone scan reveals.
• R Humerus
• R distal radius
• R ulna
• Tip R scapula
• L midshaft ulna.
• R distal femur
• R proximal tib/fib.

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Where did we go wrong?

• How could this have been prevented?
• Whats the use?

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What was done correctly?

• Identification of indicators
• Facial bruising
• Night terrors
• Inconsistent bite mark.
• Combative.
• Mothers concerns.
• Isolated.

• Appropriate Action.
• Referral.
• JHCH child protection team.
• DoCS notification.
• Discharge follow up.
• Baselines established.
• History established.

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Observations/ Documentation.

• Full repeated OBs.
• Nursing History.
• Sequence of events.
• Appropriate documentation

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• Thankyou
• Any questions?

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References NSW Health Intranet. Child
Protection. NSW Department of Community Services
Website www.community.nsw.gov.au/preventing child
abuse and neglect. Child Safety
Australia www.childsafetyaustralia.com.au
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