ACUTE CARE DECISIONS

Are you examining every child for signs of abuse?

If you aren't, you should be. ED nurses need to be on the lookout for hidden injuries, patterned bruises, and stories that don't add up.

When a 7-year-old boy came to the ED after being hit by a car while riding his bike, the ED nurses "log-rolled" the child over and saw unusual marks on his back.

"A nurse thought they resembled a hanger. So we actually placed a hanger next to the injury to see if it matched up, and it did," recalls Angie Black, RN, BSN, clinical educator for the ED at Children's Memorial Hospital in Chicago. "The father confessed when asked about the injuries."

She notes that every trauma patient is "log-rolled. That is so we can inspect and palpate the back for any injuries," Black says. "They were not looking for abuse. They just happened upon it."

Here are effective ways to assess pediatric patients for child abuse:

• Undress every child. When a 6-year-old boy was sent to the urgent care center at Black's facility for vomiting, he was unable to tolerate oral fluids, so he was sent to the ED for intravenous (IV) fluids.

"When I helped him change into a gown before starting the IV, I noticed multiple bruises to the abdomen and flank area, as well as bite marks, which turned out to be from an adult," she says.

Black emphasizes that all of the bruises were in areas that were hidden by clothing. "Had we not undressed him, we would not have known that he was a victim of abuse," she says.

Black urges you to undress every child, regardless of his complaint. She explains that most injuries from abuse are in areas that would be covered by clothing. Undressing the child ensures that you will see any hidden bruises or markings.

Deborah St. Germain, RN, MN, a clinical nurse specialist at Louisiana State University Health Sciences Center in New Orleans, adds that you should fully undress children down to their underpants and, at some point, remove their undergarments to look for genital trauma.

"ED nurses have been given a wonderful opportunity to screen a child when a parent brings them to the facility, but most of the time no one ever undresses them to look," she says.

While examining a child, St. Germain tells the parent that she is looking for a rash, which would indicate an illness. "Remember that abusers purposely target areas not visibly seen to avoid detection, such as areas under a shirt, pants, or socks," she says.

• Check that the mechanism of injury matches the story given by the child or caregiver. Black gives the following example of an inconsistency: A caregiver states that her infant rolled off a low sofa onto a carpeted floor, but the infant has a subdural hematoma and retinal hemorrhage. "This should pique your suspicion," she says.

She adds that two other red flags are a delay in seeking medical treatment and inconsistent stories among family members.

• Watch for red flags. Black says that certain injuries should cause you to suspect child abuse, including bruises to thighs or buttocks, circumferential or symmetrical burns, transverse or spiral fractures, femur and skull fractures in infants, and rib fractures.

Lynn Daum, RN, BSN, an ED nurse at Children's Hospital Medical Center in Cincinnati, says to be suspicious of bruises that are not in places where children normally get bruises from playing. Because children are prone to falling, whether they are learning to walk or playing with friends, they tend to get bruises on shins and scrapes on knees, she explains.

She gives the following examples of suspicious injuries: bruises to the buttocks, back, and back of the arms. It is hard to cause bruising to those areas by falling, she explains. "We try to 'catch' ourselves, so to speak, and the bruises reflect that," says Daum.

Also look for bruises that are in "patterns," she adds, such as handprints, finger marks, blisters in the pattern of the sole plate of an iron, or marks on a back that look like they were made with a belt or electric cord.

• Don't ask leading questions. Black advises against asking questions such as "Did John touch your pee-pee?" as this could be challenged in court and can affect the accuracy of a child's response. Instead, she recommends having someone experienced in forensic interviewing speak with the child, such as a social worker or sexual assault nurse examiner.

"When documenting, use quotation marks and 'patient states,'" she adds.

• Take pictures of all suspicious injuries. "I was told by a district attorney in Chicago that a picture says a thousand words in the eyes of a jury," says Black.

This article was adapted from one that appeared in sister company American Health Consultants' newsletter "ED Nursing." For a subscription to this or any other AHC newsletter, call, toll-free, (800) 688-2421, or visit www.ahcpub.com .

 

Are you examining every child for signs of abuse?. RN 2003;2:28ac4.

Published in RN Magazine.