Appendicitis/Appendectomy: Unfolding Reasoning Case Study, Exams of Nursing

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Student-Appe- Unfolding ReasoningStudent-Appe- Unfolding Reasoning

Appendicitis/Appendectomy

UNFOLDING Reasoning

John Washington, 14 years old

Primary Concept Inflammation Interrelated Concepts (In order of emphasis)

• Pain
• Stress
• Clinical Judgment
• Patient Education
• Communication

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

Case Study

Safe and Effective Care Environment

✓ Management of Care 17-23% ✓ ✓ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity

✓ Basic Care and Comfort 6-12% ✓ ✓ Pharmacological and Parenteral Therapies 12-18% ✓ ✓ Reduction of Risk Potential 9-15% ✓ ✓ Physiological Adaptation 11-17% ✓

O2 sat: 99% RA T iming: Continuous

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: -Fever -Tachycardia -8/10 pain -146/76 BP -Sharp, cramping, continuous pain

-Fever can be a sign of infection -Pain level indicative of inflammation

• Elevated vital signs could be sign of peritonitis

Initial Assessment by Primary Nurse What body system(s) will the nurse most thoroughly assess based on the problem and the clinical data collected to this point? (Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System(s): PRIORITY Nursing Assessments:

-GI Assessment

-Integumentary (for hydration

status)

-Vital signs -Bowel sounds -Appetite -Last BM and characteristics of the BM (diarrhea, constipation) -Abdominal assessment (Inspect, Auscultate, Percuss, Palpate) -S/S of rupture or complications -McBurney point -Rovsings sign -Skin turgor

Current Assessment:

GENERAL SURVEY: Alert, oriented, pleasant, appears tense, uncomfortable, dress appropriate for the season, hygiene and grooming normal for age and gender. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4) HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, rebound tenderness in RLQ to gentle palpation. Rebound tenderness present in RLQ, BS + in all four quadrants, bowel sounds diminished/hypoactive GU: Voiding without difficulty, urine clear/dark amber INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. Cap refill <3 seconds. Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: -Tense -Rebound tenderness in RLQ -Diminished/hypoactive bowel sounds

-Patient could be tense and guarding due to pain and concern for condition

- Rebound tenderness is a sign of appendicitis on palpation -Poor peristalsis and less gastric content related to nausea and vomiting

Radiology Reports:

What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation) Ultrasound: Abdomen

Results: Clinical Significance: Enlarged, non-compressible appendix

-This could indicate extreme inflammation causing extreme pressure which could be indicative of impending rupture

Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 14.5 15.2 245 88 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

(Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance:

WBC 14.

Neutrophils 88%

-Elevated WBC indicate inflammation and/or infection -Neutrophils are elevated in attempts to rid the body of infection

Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 133 3.5 95 0.

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance:

Na 133 K 3.

Sodium is slightly decreased due to the patient’s vomiting and not eating or drinking since this morning. Potassium should also be closely monitored because it is just within normal limits. Due to the vomiting, all electrolytes need monitored closely, especially since this patient is at high risk.

Establish peripheral IV

0.9% NS 1000 mL IV bolus

Morphine 2 mg IV every 2 hours PRN

Ondansetron 4 mg IV every 4 hours PRN nausea

Ceftriaxone 1 g IVPB x now

Metronidazole 500 mg IVPB every 12 hours

General surgeon consult

Strict NPO

-To have access to a vein for possible surgical intervention, antibiotic administration and IVF.

-This is to maintain fluid and electrolyte balance.

-This is to help patient with pain.

-This is given to decrease patient’s nausea.

-This is an antibiotic given for patient’s infection.

-This is another antibiotic given for the patient’s infection.

-Consulting general surgery is important in case an appendectomy or other procedure is indicated, the surgeon knows the patient’s situation and is ready.

-NPO is needed for potential surgery.

-Maintain fluid and electrolytes and prepare for surgery or medication administration. -This is indicated due to patient’s NPO status and vomiting.

-Decreased pain from 8/10 to a lower level.

-The patient will no longer feel nauseous or in turn, vomit.

-Antibiotics will decrease the amount of invading bacteria in the body which will also decrease WBC.

-Patient can get relief from surgical procedure.

-Bowel rest needed for surgery for safe procedure.

PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care)

Care Provider Orders: Order of Priority: Rationale:

• Establish peripheral IV
• 0.9% NS 1000 mL IV bolus
• Morphine 2 mg IV every 2 hours PRN
• Ondansetron 4 mg IV every 4 hours PRN nausea
• Ceftriaxone 1 g IVPB x now
• Metronidazole 500 mg IVPB every 12 hours

-Establish IV -Morphine 2 mg IV q2h PRN -0.9% NS 1000 mL IV bolus -Ceftriaxone 1g IVPB x now -Metronidazole 500 mg IVPB q12h -Ondansetron 4mg IV q4h PRN nausea

-IV access must be established first prior to giving any medications -I would then medicate the patient with morphine for his pain to make him more comfortable ASAP -I then would hang the normal saline and Ceftriaxone antibiotic since it is ordered now. -I then would give Metronidazole and Ondansetron last because it is only PRN for nausea.

Collaborative Care: Nursing

2. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY: -Rupture and/or further complication prevention

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

-Frequent vital sign monitor -Pain assessment and reassessment with medication -Focused GI assessment -Medication administration

-To monitor increasing severity or worsening of infection. -Assessing rate, quality and locations of pain to monitor infection progression. -GI assessment is important to assess the status of the patient’s appendicitis -Medication administration needed to decrease pain and treat infection to hopefully prevent further complications

-Performing all of these assessments allow the nurse to know the patient’s condition at all times so it is known when doctor or further intervention is needed.

• Medications will hopefully lessen the patient’s symptoms 3. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: PRIORITY Nursing Assessments:

-GI Assessment

-Integumentary (for hydration status)

-Vital signs -Bowel sounds -Appetite -Last BM and characteristics of the BM (diarrhea,

PRIORITY Nursing Interventions: Rationale:^ Expected Outcome:

CARE/COMFORT:

Caring/compassion as a nurse

Physical comfort measures

-Diversional activity -Facetime or visits from family and friends -Allow patient to watch movies or TV shows that he enjoys -Place patient in High Fowlers position to decrease abdominal pressure -Ensure patient has warm blankets as necessary -As diet advances, get patient snacks that he enjoys -Allow expression of feelings

-Patient will feel more comfortable. -Patient will be educated on procedure, condition and surgery so he is not as scared or anxious. -Patient can keep in touch with loved ones.

EMOTIONAL (How to develop a therapeutic relationship): Discuss the following principles needed as conditions essential for a therapeutic relationship:

• Rapport
• Trust
• Respect
• Genuineness
• Empathy . -It is essential for the nurse to develop a good rapport with the patient that way the patient feels comfortable expressing his feelings to the nurse and trusts the nurse with his care. Good rapport and trust also is established through mutual respect, being genuine and honest with one another and for the nurse to be empathetic. All of these are key components to a good patient-nurse relationship. It is important to have this relationship so there is thorough and therapeutic communication, This also will alleviate anxiety for the patient and make their experience in the hospital better overall.

-Patient will feel comfortable to express feelings to the nurse and thoroughly explain what is going on. The patient will not be as anxious or afraid to ask questions regarding his condition and will feel respected and understood.

SPIRITUAL: Hopelessness related to recovery period and hospitalization taking away from sports and social interaction

-Patient will be educated on the typical recovery times and activity restrictions and will be reassured that he is able to see his friends and family soon and will be able to get back on the field if he abides by the restrictions.

Evaluation: Four Hours Later…

John had a laparoscopic appendectomy without apparent complications. He is currently in PACU and has just returned to the med/surg floor.

Current VS: Most Recent (from

PACU):

Current PQRST:

T: 100.4 F/38.0 C (o) T: 99.8 F/37.7 C (o) P rovoking/Palliative: Movement worsens

P: 92 (reg) P: 84 (reg) Q uality: Dull ache

R: 20 (reg) R: 18 (reg) R egion/Radiation: RLQ

BP: 136/86 BP: 124/80 S everity: 5/

O2 sat: 97% room air O2 sat: 99% room air T iming: Continuous

Initial Postop Assessment by Primary Nurse What body system(s) will the nurse most thoroughly assess based on the problem and the clinical data collected to this point? (Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System(s): PRIORITY Nursing Assessments:

-All body systems must be

assessed when returning from

surgery. This is indicated due to

patient being under anesthesia and

ensuring their condition is

returning to normal.

-It is important to do

reassessments on the GI system

because this is where and why

surgery took place

-ABC’s -Vital signs -Surgical site -Pain assessment -GI reassessment -Neurological -HEENT -Respiratory: lung sounds, etc. -Circulatory/Cardiovascular assessment: capillary refill, etc. -Skin assessment

Current Assessment: GENERAL SURVEY: Appears to be in no acute distress, the body appears tense. Occasional moans; moves as little as possible and grimaces with movement. NEUROLOGICAL: Drowsy, but arousable, alert & oriented to person, place, time, and situation (x4) HEENT: Head normocephalic with the symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Respirations shallow, breath sounds clear but diminished with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen flat and tender to gentle palpation. No BS auscultated in all four quadrants. Three small dressings on the abdomen with no drainage present GU: Has not voided since surgery INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. Cap refill <3 seconds, Hair softdistribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable:

-Temperature -HR -SpO -Respirations

-All vital signs are starting to decline and stabilize which is a good sign after surgery. This shows that there are no complications and the problem is fixed so

-Improving

need of further intervention or other complication BM and voiding monitor is important to assess for complications and to monitor progress for discharge.

Collaborative Care: Postop Medical Management (Pharmacologic and Parenteral Therapies)

Care Provider Orders: Rationale: Expected Outcome: Morphine 2-4 mg IV every 4 hours PRN pain

Ondansetron 4 mg ODT every 8 hours PRN nausea

Ceftriaxone 1 g IVPB every 12 hours

Metronidazole 500 mg IVPB every 12 hours

D5 ½ NS w/20 mEq KCl 75 mL/hour until tolerating PO fluids

This helps patient with pain.

This medication is given for nausea.

This is an antibiotic now being given prophylactically for post op infections and keeping original infection gone.

This is another antibiotic.

These fluids are given for fluid and electrolyte balance.

Pain will be decreased and eventually non- existent. Patient will no longer experience nausea, especially with meals. Antibiotics are given to get rid of any infection the patient may have from surgery. The patient will maintain a normal fluid and electrolyte balance prior to discharge.

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient who is now fours postop: (Management of Care)

S ituation:

Name/age: John Washington, 14 years old

Summary of the primary problem: Patient had emergency appendectomy

Day of admission/post-op #: Admitted today, post op #1 today

B ackground:

Primary problem/diagnosis: Patient presented to the ED with excruciating RLQ pain and was experiencing nausea

and vomiting.

RELEVANT past medical history: None

A ssessment:

Most recent vital signs: 99.8 T, 84 P, 18 R, 124/80 BP, 99% SpO2 on room air

RELEVANT body system nursing assessment data: All systems WNL with the exception of GI. Abdomen

was flat and tender with palpation. No bowel sounds were present in all four quadrants. Three small

dressings on abdomen with no drainage. Patient is showing nonverbal signs of pain such as guarding and

grimacing.

RELEVANT lab values: WBC was elevated to 14.5 prior to surgery and neutrophils were 88%. Sodium

was slightly low at 133. Lactate was 4.1 and CRP was 55.

TREND of any abnormal clinical data (stable-increasing/decreasing): Patient is beginning to stabilize.

Vital signs are coming back down to baseline and all abnormal assessments are typical in post op

appendectomy patients. Will continue to monitor.

How have you advanced the plan of care? Educating the patient on incentive spirometry and deep

breathing. Also encouraged the patient to ambulate as tolerated. Patient is in High Fowlers position to

decrease pressure on the incision for comfort. Dressings are clean, dry and intact.

Patient response: Patient is still tense and grimacing from post-op pain but medications are being

administered as ordered. Patient is avoiding movement but frequently being encouraged to ambulate.

INTERPRETATION of current clinical status (stable/unstable/worsening): Stable, the patient is no

longer in excruciating pain and reports no nausea.

R ecommendation:

Suggestions to advance the plan of care:

-Ambulate 3x a day/as tolerated -Advance diet as tolerated once bowel signs return -Incentive spirometer every hour -Encourage PO fluids -Wound care -Monitor for infection -Reassessment and VS frequently

-I learned that appendicitis is a very severe

condition that can lead to severe complications

quickly if not addressed and treated.

-I think that prioritizing nursing assessments,

interventions and medication administration allowed

me to piece together what I know and utilize my

critical thinking skills.

What could have been done better? What is your plan to make any weakness a future strength?

-I think that more background information would have been more beneficial for the situation.

It is important to always be prepared for a number of situations because healthcare in general is not predictable and you must be able to react to even the most severe situations in a quick and efficient manner to give the patient the best treatment possible.