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Case Study 124 Appendicitis
Scenario
R.O. is a 12-year-old girl who lives with her family on a farm in a rural community. R.O. has four siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were seen by their primary care provider (PCP) and diagnosed with viral gastroenteritis. A week later, R.O. woke up at 0200 crying and telling her mother that her stomach “hurts really bad!” She had an elevated temperature of 37.9 ° C (100.2 ° F). R.O. began to vomit over the next few hours, so her parents took her to the local emergency department (ED). R.O.'s vital signs, complete blood count, and complete metabolic panel were normal, so she was hydrated with IV fluids and discharged to home with instructions for her parents to call their PCP or to return to the ED if her condition did not improve or if it worsened. Over the next 2 days, R.O.'s abdominal pain localized to the right lower quadrant, she refused to eat, and she had slight diarrhea. On the third day, she began to have more severe abdominal pain, increased vomiting, and fever that did not respond to acetaminophen. R.O. has returned to the ED. Her VS are 128/78, 130, 28, 39.5 ° C (103.1 ° F). R.O. is guarding her lower abdomen, prefers to lie on her side with her legs flexed, and is crying. IV access is established, and morphine sulfate 2 mg IV is administered for pain. An abdominal CT scan confirms a diagnosis of appendicitis. R.O.'s white blood count is 12,000 mm3.
- Which of the following are common clinical manifestations of appendicitis? Select all that apply. a) Diarrhea b) Vomiting c) Left lower quadrant abdominal pain d) Constipation e) Arthralgia f) Diffuse rash g) Fever Answer: Diarrhea, Vomiting, Constipation, and Fever a, b,d, g
- Discuss why R.O.'s presenting clinical manifestations make diagnosis more difficult. Identify two other possible diagnoses. Answer: R.O’s symptoms presented first were very vague and the PCP could not distinguish the exact diagnosis. When looking at her symptoms of stomach pain, vomiting, diarrhea, and fever she was diagnosed with viral gastroenteritis. R.O’s diagnosis most likely looked like a flare up, and proceeded to get worse after medical intervention.
**1. Inflammatory bowel disease (IBS)
- Crohn’s disease** 2b. What are the early and late signs/symptoms of appendicitis and special clinical signs? Answer: Early signs of appendicitis include dull pain near the naval or upper abdomen becoming sharp as it moves to the lower right abdomen, loss of appetite, nausea, vomiting, abdominal swelling, fever, and inability to pass gas. Late signs or signs rarely seen include dull or sharp pain in the upper or lower abdomen, back, or rectum, painful urination or difficulty passing urine, severe cramps, and constipation or diarrhea with gas. Case Study Progress The abdominal CT scan confirms that R.O. has appendicitis. The ED physician has written orders. 3. Note whether the orders are appropriate or inappropriate and give rationale. Chart View Emergency Department (ED) Orders a. Make patient NPO b. Place a peripheral IV and begin D5.NS at 80 mL/hr c. Administer Fleet Enema now to rule out impaction d. Administer morphine sulfate 2 mg IV q2h for pain e. Obtain surgical consent from patient f. Administer cefotaxime (Claforan) IVPB, at 150 mg/kg/day q6h a. Appropriate: NPO orders help to prepare for surgery b. Appropriate: Patient needs to maintain a balance of electrolytes and fluids. c. Inappropriate: May erupt appendix d. Appropriate: morphine dose and time is appropriate for pain e. Inappropriate: Patient is not old enough to sign consent form f. Appropriate: This antibiotic is being given to help prevent infection 4. R.O.'s weight is 42 kg, and her height is 155 cm. Calculate her maintenance fluid needs and discuss how these will be met. To calculate maintenance fluid needs, use the following formula
- The first 10 kg of weight x 100 mL
- 11 to 20 kg of weight x 50 mL
- Over 20 kg of weight x 20 mL (The weight remaining after the first 20 kg) Answer: 10kg x100mL= 1,000mL 20kg x 50mL=1,000mL 12kg x 20mL= 240mL
Teach about comfort measures, fluid therapy, pain control, and educate parents the patient will remain NPO. Antibiotics, antipyretics, and IV fluid replacement. Educate parents on signs and symptoms that the patient may experience, alone with adverse effects and complications that need to be reported as soon as possible. Explain the procedure to R.O. and her parents. Case Study Progress R.O. undergoes an appendectomy; the appendix has ruptured. The peritoneum is inflamed and abscesses are seen near the colon and small intestine. R.O. is admitted to the surgical unit; she is NPO, has a nasogastric tube (NGT), Foley catheter, IV line, abdominal dressing, and a Penrose drain.
7. Identify the priority nursing considerations. Select all that apply. a. Reduced bowel function b. Pain c. Skin integrity changes d. Cardiac output changes e. Changed family processes f. Potential hypothermia g. Potential fluid and electrolyte imbalance a, b, e, g Case Study Progress On postoperative day 2, R.O. continues to improve and is tolerating ice chips. Breath sounds are clear, and she is performing her pulmonary hygiene. NGT has minimal drainage. The Foley catheter and Penrose drain have been removed, and her urine output is adequate. Her IV line is saline locked. The incision is well approximated with no drainage or redness. Her pain is 4 to 6 out of 10 with pain medication every 4 hours. Later that evening your assessment shows that R.O. is pale and listless; bowel sounds are absent; abdomen is distended and tender to the touch; the NGT is draining an increased amount of dark, greenish black fluid. Her lung sounds are moist bilaterally, and her temperature has spiked to 40.2 ° C (104.4 ° F), O2 saturation is 97% on room air. She rates her pain at 10 out of 10 and is having difficulty taking deep breaths because of the pain, which she says “hurts over my whole stomach.” 8. What actions would you take? Answer: I would give any PRN pain medications ordered by the doctor as soon as possible. I would immediately call the doctor and report findings. Patient’s fever is extremely high, and give her cold packs as non-pharmacological therapy. Have patient explain pain’s quality and location as part of documentation. Closely monitor patient every 15 minutes.
9. Using SBAR, what would you communicate to the surgeon? S Pt is a 12-year-old female, full code, with NKA. Pt is 2 days postoperative. Pt has an NGT with minimal drainage, inadequate urine output, IV Saline lock. Pt has incision that is well approximated with no signs of infection. Pt is in a lot of pain is reporting SOB, and has a fever of 104.4 °. Pain has been managed with medication. B Pt originally was diagnosed with viral gastroenteritis by her primary health provider with symptoms of vomiting, diarrhea, and a fever. After a week the pt was brought into the ER with a fever and vomiting for a few hours. Pt was treated and was discharged. It wasn’t until 2 days later the pt came back with lower right quadrant abdominal pain and an elevated fever again. Her VS are 128/78, 130, 28, 39.5 ° After a CT scan indicating appendicitis. Pt underwent an appendectomy where the appendix unfortunately ruptured. The patient was taken to the surgical unit with placement of an NGT, Foley, Penrose drain, and IV saline lock. Pt has been closely monitored. A After two days post op the pt is reporting worsening pain of 10/10, increased fever, lung sounds are moist bilaterally, and pt reports difficulty taking deep breaths with a pain radiating through whole stomach. Pt abdomen is distended and tender to the touch, NGT is draining dark, greenish black fluid. R I would recommend a full laboratory testing, CBC, CT scan. I would recommend working the pt’s health care team to ensure proper treatment for pt, with the most efficient plan of care. I would recommend keeping pt NPO, and explaining everything to parents so everyone is in the know. Pt is in a lot of pain and that needs to be under control with PRN pain medication per MD orders. 10. What will you consider as part of your nursing management of R.O.'s pain? It is important to make sure the nurse is in full understanding of R.O.s pain quality, quantity, location, aggregating and alleviating factors. It is important to implement all non- pharmacological interventions that help manage R.O.s pain, and keep implementing until pharmacological medication is ordered and needed. Case Study Progress The surgeon assesses R.O. and orders an immediate return to the operating room. R.O. returns to surgery, where she has lysis of adhesions, removal of necrotic bowel, and drainage of an abscess. The surgeon has left her abdominal wound open and has ordered wound packing changes twice daily and abdominal irrigation with normal saline. R.O. cries and becomes agitated when you go to perform the procedure. 11. Which of the following pain and coping concepts would you question as you assist R.O to prepare for the procedure? a. R. may fear loss of control during the dressing change. b. R. may fear separation from family members during painful experiences. c. R. is concerned about privacy during the dressing change. d. Prior coping strategies can be used to prepare for the dressing change.
b
12. In anticipation of R.O.'s discharge, identify expected outcomes that must be achieved before discharge from the hospital. Answer: Patient will verbalize a decrease in pain that is tolerable for R.O. Patient will reach optimal fluid and electrolyte balances. Patient will verbalize measures on how to manage pain at home, and things to look out for following surgery. Patient will have a clean, dry, intact incision site with optimal healing and no sign of infection. Case Study Progress After a week, R.O. continues to meet expected outcomes, with her wound healing well. Her discharge to home is planned for the next day. You provide discharge teaching to R.O. and her parents. 13. Which of these statements would indicate that more teaching is required? a. “We need to return if R.O. begins vomiting again or develops a fever.” b. “R.O. should wait 1 week before returning to her gymnastics program.” c. “We will keep the incision clean and call if we see redness or drainage.” d. “R.O. can advance her diet to the regular foods that she likes to eat.” Answer: b. 14. How would you meet the play needs of your patient? Have friends come and interact with patient. Encourage favorite items from house to bring a familiar and safe feeling. Establish pt’s favorite hobbies and try to implement them in patient’s stay. Reading and listening to music. Allowing books to read from home. Case Study Outcome R.O. is discharged to home with her parents and has an uneventful recovery. She is scheduled for a follow-up visit with the surgeon in 2 weeks. 15. What are the possible complications? Peritonitis which is an inflammation or infection of peritoneal cavity. Abscess that may form. There could even be a perforation of the appendix. Nursing Process Formulate two nursing diagnosis related to the scenario and write a care plan for one diagnosis. 1. Risk for deficient fluid volume related to preoperative vomiting, diarrhea, and loss
of appetite.
