Case Study on Submersion Injury

This case study discusses the collaboration of medical experts in supporting the family, educating parents on pain assessment, administering morphine, pathophysiology of submersion injury, impact on family, and creating a nursing care plan.

Running head: CASE STUDY ON SUBMERSION INJURY
CASE STUDY ON SUBMERSION INJURY
Name of the Student
Name of the University
Author Note

1
CASE STUDY ON SUBMERSION INJURY
1. The team of doctors want to discuss Mikey’s long term options with the family. Discuss how
the team (including doctors, nurses, social workers) can collaborate and implement
interventions that can best support the family while having such an important discussion.
While having such an important discussion regarding Mikey’s current condition, the
medical experts (doctors), nurses, neurologists, psychologists/psychiatrists, health care
workers/ social workers of can collaborate and form a ‘core medical team’ (Hockenberry
& Wilson, 2018).
Doctors (Medical experts): Medical experts or doctors carefully observe the condition of
Mikey and provide essentials medication and treatments to him.
Nurses: Nurses should properly monitor the condition of Mikey. They should monitor
Mikey’s blood pressure level and oxygen saturation level in regular basis. They should
also clear the bronchial airways by properly placing the endotracheal tube (Meyer,
Theodorou & Berg, 2014).
Neurologists: Neurologists should minutely observe the oxygen level of brain and try to
recover Mikey from coma condition. They should also try to assess the motor responses
of Mikey.
Psychologists: Psychologists should provide mental support to Mikey’s parents.
Social workers: Social workers can help the family financially by seeking financial help
from Government.
2. The parents are very concerned about if Mikey is comfortable or not. How would
you educate the parents on how nurses assess for pain in this population? Discuss
the pain scale that you would use. What kind of pain control do you think is
appropriate for this patient? Do you think he may require sedation? What might be
the risks of using sedation and/or pain medication? How would you educate the
family about the use of sedation? Use a reference to support your rationale.

2
CASE STUDY ON SUBMERSION INJURY
The main aim of assessment of a pediatric pain is to establish how much pain the child (in
this case Mikey) is experiencing.
The behavior pain measurement scale named COMFORT scale is appropriate for this
patient. This scale is the best unobtrusive scale for measuring the distress in ventilated
infants. The COMFORT scale has eight indicators: alertness, calmness/agitation,
respiratory response, physical movement, blood pressure, heart rate, muscle tone, and
facial tension (Howard 2014).
Considering the fact that Mikey is unresponsive to any external, internal as well as
emotional stimuli pharmacological pain control management is appropriate for this
patient.
Mikey may require sedation as tool of pharmacological pain management.
Using of sedatives may develop various side effects as well as risk factors. These side
effects and risk factors include constipation, nausea, respiratory depression and miosis.
I would educate the family about the pediatric sedation. Pediatric sedation is completely
different from adult sedation. This type of sedation further helps to reduce the fear and
anxiety in children (in this case Mikey).
3. The physician orders morphine for to help manage Mikey’s pain. He orders
0.1mg/kg/dose IV every 4 hours. Calculate the final dose you will administer to
Mikey as well as how much volume of medication you will administer. Mikey weighs
24 pounds. The concentration of morphine is 0.5mg/1ml.
For every 4 hours IV dose is 0.1mg/kg
For every 24 hours = 0.6mg/kg
Considering the fact that Mikey weighs 24 pounds= 10.89kg.
So the final dose = (6.53/0.5)=13.06 mL.

3
CASE STUDY ON SUBMERSION INJURY
4. Now discuss the action of morphine, its potential side effects, nursing considerations,
and how fast you can administer it to a child this age.
The action of morphine includes the analgesic property. Morphine is used for both acute
and chronic pain. Morphine can be used before and after surgery. Other actions of
morphine also include papillary constriction, depression of cough reflex, respiratory
distress (Schwarz & Bilbo, 2013).
Potential side effects of morphine include constipation, nausea, pruritus, dysphoria,
urinary retention and so on.
Morphine should always be administered with naloxone (Schwarz & Bilbo,
2013).Naloxone antagonizes the effects of morphine if there is any sign of cardiac or
respiratory depression (Webster 2015).Considering Mikey’s age, morphine should be
administered by slow intravenous (IV) injection. In case of infants, the doses and volumes
of morphine are initial and maximal doses.
5. The team informs the family that Mikey has suffered from a submersion injury.
Discuss the pathophysiology of this type of brain injury, risk factors, possible
outcomes, and prognosis. How might the nurse offer some resources and support to
this family, including the sibling during this time of diagnosis and prognosis? What
are some common responses in parents who face situations like this?
Pathophysiology of submersion injury includes hypoxia, respiratory acidosis, aspiration
and hypothermia. The principal risk factor for submersion injury is cerebral hypoxia.
Cerebral hypoxia is referred as the reduced supply of blood to brain.
Reduced blood supply to brain may lead to the development of brain death or coma in
infants (in case of Mikey). According to different scientific reviews, cerebral hypoxia is
the major cause of morbidity and mortality in case of submersion events. Prolonged
drowning in water (cold liquids) may affect the cognition of brain, muscle tone and

4
CASE STUDY ON SUBMERSION INJURY
coordination (Thomas 2017).Cerebral hypoxia most often occur due to the damage or
injury in the cardio-vascular system and respiratory system (Ball, Bindler, R. C., &
Cowen, 2013).
Nurses should give endotracheal incubation and mechanical ventilation to the patient
affected with submersion injury (In this case Mikey). Proper level of blood gases and pH
are monitored regularly to observe the exact oxygen, fluid, and electrolyte. Considering
the fact that Mikey’s oxygen saturation level has been increased from 33% to 75%, there
is a chance of recovery of Mikey from his present condition. Moreover, withdrawing
active support, such as nutrition and the breathing tube from Mikey should not be done as
euthanasia should involve patient’s concern. Considering the fact that the patient (In this
case Mikey) is not an adult and in this case euthanasia can be decided by his parents only.
However, to perform euthanasia on an infantile is ethically wrong.
6. Discuss Mikey’s sibling’s response to the hospitalization and family stressor. What
kind of behavior is she demonstrating? Describe which developmental stage she is
likely is in and its implications on her response and behaviors.
Various factors have been observed that influence the Mikey’s sibling’s response to
hospitalization.
As Mikey has a healthy 4 year old sister who has been at the hospital with the family to
see Mikey she feels lonely. Her responses also include fear, anger, jealousy. Nervous
system impairment and cognitive impairment can also be seen in Mikey’s sister.
According to Erikson’s developmental stage theory during her early childhood days she
should develop a proper postural capacity, become independent to perform urination as
well as try to walk alone (Hockenberry & Wilson, 2018). On the contrary, seeing her
brother in that particular condition, fear, anxiety (induced by trauma) developed within
her. As a consequence she does not want to stay alone.

5
CASE STUDY ON SUBMERSION INJURY
7. Discuss the criteria for establishing brain death in Mikey’s age group. Explain the
process of evaluation as if you are teaching Mikey’s parents who do not have any
medical background. Discuss how a family may be impacted by having a child with
a tracheostomy tube. Use a family theory (Bowen Family Systems Theory, Duvall’s
Developmental Theory, or Family Stress Theory) to evaluate how the family system
may be impacted.
Mikey has been suffering from submersion injury. Cerebral hypoxia is the most
common condition developed due to submersion injury. Considering the fact that Mikey’s
age is around 18 months brain death may develop due to cerebral hypoxia.
A family should be very cooperative and careful towards the child having a
tracheostomy tube. They should also be very brave and psychologically stable. They
should also be taken care of the fact that a child with a tracheostomy tube should avoid
dirty and dusty places.
Family stress theory is absolutely appropriate for the above described situation of Mikey
and its family. This theory is a developmental theory which illustrates why some family
systems often acclimatize and even develop and adapt with different situational stressors
(Semple-Hess & Campwala, 2014). Mikey’s parents efficiently and quickly acclimatize
with the current situation of Mikey considering the fact that Mikey’s condition remains
drastically severe for several months.
8. Create a nursing care plan starting with a nursing diagnosis appropriate for this
patient and/or family for the next two week of the hospitalization. Include your
assessment that supports your nursing diagnosis, goals for outcomes,
interventions (supported by peer-reviewed rationales), planning,
implementation, and evaluation.
Nursing care plan for submersion injuries are described below

6
CASE STUDY ON SUBMERSION INJURY
Nursing Interventions Rationale
Mikey’s consciousness
level should be measured.
Considering the fact that Mikey has been suffering from cerebral hypoxia.
Mikey’s respiratory rate
and blood pressure should
be monitored
Low blood pressure.
Auscultator lung of Mikey
(Produce sounds such as
crackles, wheezing)
Crackles occur due to the fluid accumulation in the bronchial airways that
eventually develops pulmonary oedema.
Bronchospasm may develop wheezing sound.
Assessing for any signs of
severe pulmonary oedema.
Pulmonary oedema is characterised by pink and frothy sputum.
Monitoring oxygen
saturation level minutely
by using finger-pulse
oxymeter.
Oxygen saturation level should always be 90% or greater. Reduced oxygen
saturation level as well as decrease in partial pressure of oxygen is a
indication of respiratory failure (Hockenberry & Wilson, 2018).
Chest X-ray of Mikey
should be done and
monitored minutely.
The severity of lung injury and aspiration can be assessed minutely by chest
X-ray
Provide proper Supplemental oxygen can be administered by giving oxygen mask to Mikey.

7
CASE STUDY ON SUBMERSION INJURY
oxygenation to Mikey as
needed.
Intubation as well as
mechanical ventilation can
be administered to Mikey.
In order to prevent acute respiratory syndrome and coma intubation and
mechanical ventilation is essential.
Bronchoscopy
Bronchoscopy includes insertion of thin, flexible and long camera inside the
bronchial or tracheal airways. It helps to diagnose whether the fluid
accumulates inside the lung or not (Hockenberry & Wilson, 2018).
Considering the fact that acute respiratory syndrome always develops due to
submersion injuries, bronchoscopy can be performed in infants (in this case
Mikey).

8
CASE STUDY ON SUBMERSION INJURY
References
Ball, J. W., DrPH, R. N., Bindler, R. C., & Cowen, K. J. (2013). Child health nursing.
Prentice Hall.
Hockenberry, M. J., & Wilson, D. (2018). Wong's nursing care of infants and children-E-
book. Elsevier Health Sciences.
Howard, R. F., Wiener, S., & Walker, S. M. (2014). Neuropathic pain in children. Archives
of disease in childhood, 99(1), 84-89. doi: 10.1136/archdischild-2013-305731
Meyer, R., Theodorou, A., & Berg, R. (2014). Paediatric considerations in drowning.
In Drowning (pp. 641-649). Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-
3-642-04253-9_99
Palermo, T. M., Valrie, C. R., & Karlson, C. W. (2014). Family and parent influences on
pediatric chronic pain: A developmental perspective. American Psychologist, 69(2),
142. doi.org/10.1037/a0035216
Schwarz, J. M., & Bilbo, S. D. (2013). Adolescent morphine exposure affects long-term
microglial function and later-life relapse liability in a model of addiction. Journal of
Neuroscience, 33(3), 961-971.
Semple-Hess, J., & Campwala, R. (2014). Pediatric submersion injuries: emergency care and
resuscitation. Pediatr Emerg Med Pract, 11(6), 1-21. Retrieved from:
https://pdfs.semanticscholar.org/80f3/19522009713656a440f3b589ae9ec6ced92e.pdf
Thomas, A., Sanseau, E., Uspal, N., Burns, R., Auerbach, M., Caglar, D., ... & Reid, J.
(2017). Pediatric Emergency Medicine Simulation Curriculum: submersion injury
with hypothermia and ventricular fibrillation. MedEdPORTAL: the journal of
teaching and learning resources, 13. https://doi.org/10.1111/pme.12666

9
CASE STUDY ON SUBMERSION INJURY
Webster, L. R. (2015). The relationship between the mechanisms of action and safety profiles
of intrathecal morphine and ziconotide: A review of the literature. Pain
Medicine, 16(7), 1265-1277. https://doi.org/10.1111/pme.12666