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JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR140
Clinical Simulation
Instructor Handout: Child with Appendicitis
Robert Austin is a 7-year-old white male admitted to pediatrics from the emergency
department. He presented with a 24-hour history of nausea and vomiting with increasing
abdominal pain.
1. Upon admission what should be included in the physical exam?
Student performs complete physical assessment.
General appearance: Crying and guarding right lower quadrant of abdomen.
Temp 101.5
Wt. 82 lbs.
HR 122
Pain Scale: 10
RR 24
Labs: WBC 16,000
BP 122/75
Heart: regular sinus rhythm
Breath sounds: clear
Bowel sounds: hyperactive x 4
After completing your assessment, you notify the MD of your findings and receive the
following orders:
Diagnosis: R/O Appendicitis
Start IV D5 1/2 NS with 20 mEq of KCl per liter at 100 mL/hr
Gentamycin 90 mg IV q 8 hr
Morphine sulfate 2 mg 1-2 hrs prn pain
Phenergan suppository 125 mg q 4-6 hrs prn nausea
Acetaminophen appropriate dosage for weight po/pr q 4 hrs prn temp > 101
Diet: NPO except meds
2. Explain rationale for these orders and prioritize implementation.
3. What steps would you take prior to administering medication?
Prior to administering medication the student should:
° Determine if the patient has any allergies
° Ensure that the patient is voiding before administering KCl
° Check safe dosage range
° Check six rights of medication administration
4. His mother reports that she put a heating pad on his tummy at home and he
seemed to feel better. She asks if your will please do that for him here. How will
you respond?
Student should recognize danger of this practice and respond appropriately utilizing
therapeutic communication.
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5. Patient reports sudden relief of pain. How will you respond?
Student should suspect rupture and reassess patient:
General appearance: lethargic
Temp. 102.6
HR134
RR 30
BP 128/80
Heart: regular sinus rhythm
Breath sounds: clear
Bowel sounds: absent
Pain scale: pt does not respond
Student should take following actions:
° Notifies MD
° Prepares child and family for surgery
° Ensures that informed consent has been signed
°
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JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR140
Clinical Simulation
Student Handout: Child with Appendicitis
Robert Austin is a 7-year-old white male admitted to pediatrics from the emergency
department. He presented with a 24-hour history of nausea and vomiting with increasing
abdominal pain.
1. Upon admission what should be included in the physical exam?
After completing your assessment, you notify the MD of your findings and receive the
following orders:
Diagnosis: R/O Appendicitis
Start IV D5 1/2 NS with 20 mEq of KCl per liter at 100 mL/hr
Gentamycin 90 mg IV q 8 hr
Morphine sulfate 2 mg 1-2 hrs prn pain
Phenergan suppository 125 mg q 4-6 hrs prn nausea
Acetaminophen appropriate dosage for weight po/pr q 4 hrs prn temp > 101
Diet: NPO except meds
2. Explain rationale for these orders and prioritize implementation.
3. What steps would you take prior to administering medication?
4. His mother reports that she put a heating pad on his tummy at home and he
seemed to feel better. She asks if your will please do that for him here. How will
you respond?
5. Patient reports sudden relief of pain. How will you respond?
4
Date/Time
July 20th, 2007
9:00 AM
Pediatric Simulation Appendicitis and Post-Op Appendectomy
Subjective and Objective Data
Minimal Expected Student Behavior Prompts and Questions
Teaching Points
Receiving pt from ED with mother at
child’s side. Child presents with
decreased C/O pain. Is more cheerful
and trying to play.
Admission Orders:
Admit to Pediatric Floor-Dr.
Williams, Dr. Bowling-surgeon
Diagnosis: R/O Appendicitis
IV D5 ½ NS with 20 mEq KCL/L @
65cc/hr
Rocephin 900 mg IV q daily
Morphine Sulfate 2mg q 1-2/hrs IV
prn pain
Phenergan Suppository 12.5mg q 46hrs prn N/V
Acetaminophen 325 mg po/pr prn
temp>101
Diet-NPO
Activity-Bedrest with bathroom
privileges
Strict I&0
Call for acute changes in condition.
Admission Vital Signs
HR-100
AbdomenBP-90/66
Hypoactive BS
R-18
Rounded, taut &
T-100
tender.
Pain scale-1 WT-24kg, Ht.-120cm
Labs from ED (give information
when student asks for results)
Complete assessment of patient:
Vital signs with pain scale
Physical assessment
IV fluids
Name band
WT., HT. and BP
Obtains health history from parent
Child’s pain has changed from 10 to 1
in 20 minutes, should the nurse be
concerned?
What actions should she take?
(gather lab, CT results and call MD)
Calls labs for results of BMP, CBC,
UA
Calls radiology for CAT scan
Is the Rocephin dose therapeutic and
safe for this patient?
What is the action of this medicine?
What are the side effects of Rocephin?
Student should:
-calculate drug dosage for Rocephin
- use 5 rights when administering
medication.
- teach medication to parent.
- assess for drug allergies before
administering medication.
-note the conflicting orders (NPO and
Tylenol po) and call physician to
clarify
What labs are abnormal and why?
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BMP
Na.-139
K+- 4.2
Cl-108
CO2- 19
BUN-22
CR-0.6
CBC
WBC-19.7
Hgb-12.3
Hct.-37.8
PLT-433
Segs-72
Bands-15
Lymphs-12
Urinalysis
Specific gravity-1.012
Ketones- trace
Protein-trace
Microscopic cast
No bacteria, RBC’s or WBC’s
Blood Culture-pending
Urine Culture-pending
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Date/Time
Subjective and Objective Data
Minimal Expected Student behavior
CAT SCAN of abdomeninflammatory changes to RLQ in area
of appendix. Minimal amt free fluid
seen just posterior of appendix.
July 20, 2007
Time: 11:00AM
Pt is experiencing increased pain in
RLQ. Crying. Knee to chest position.
C/O nausea.
Student should do assessment with
vital signs, pain scale and call M.D.
(Dr. Williams).
Vital Signs:
Pain scale 10
HR- 120
RR-28
BP-100/70
Temp-100.8
Student should incorporate assessment
findings, pain scale, vital signs and lab
reports and CT scan results when
reporting to MD.
NEW ORDERS FROM M.D.
Prepare child for surgery
Have OP permit signed
Give Morphine Sulfate 1 mg IV push
now for pain.
Insert foley catheter
Increase IV fluids to 125cc/hr
Prompts and Questions
Teaching Points
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Date/Time
Subjective and Objective Data
Minimal Expected Student behavior
Prompts and Questions
Teaching Points
Complete assessment:
All body systems
IV fluids
Foley catheter
NG tube.
Pain scale
Why are there no bowel sounds?
POST-OP APPENDECTOMY
July 20, 2007
Time: 4:00PM
Patient returning from surgery.
Drowsy but awakens to name being
called.
Diagnosis: Ruptured Appendix.
Post-Op Orders:
Vital Signs q 2 hrs.
Bedrest
Strict I & O
NPO
CBC, BMP in AM
IV fluids- D5 LR at 75cc/hr.
Zosyn 250 mg IV q 6 hours
Fortaz 100mg IV q 8 hours
Morphine Sulfate 0.5 mg q 1-2 hours
prn pain
Tylenol 325 mg PR q 4 hours prn pain
or temp> 100.5.
Keep NG tube to low suction.
Vital Signs
HR-110
RR-24
Temp-99.8
BP – 110/74
Pain Scale-3 on arrival to floor
Lungs- faint rales
Abd- No bowel sounds
Dsg- RLQ dry and intact
Calculate Drug doses for safe range
And properly administer
What is the purpose of the NG tube?
Medications
Purpose
Reason for 2 antibiotics
Teaching needed on SE of all
meds.
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Date/Time
Subjective and Objective Data
July 21, 2007
Time: 8:00am
Awake. C/O of NG. “Wanting it out”.
IV- D5LR @75cc/hr
CBC and BMP drawn @ 6:00 AM
Assessment:
N/G tube continues to suction
Pain Scale: 4 since receiving med at
7:00am
HR- 80
RR-20
T-99.7
BP- 100/72
Lungs- clear
Abdomen- No Bowel Sounds,
distended and tender
Foley catheter intact.
CBC- WBC-16.3
Hgb-9.5
Hct.-26.8
PLT-250,000
BMP- Na-140
K+-3.2
Cl-106
CO2-22
BUN-16
CR-0.5
Minimal Expected Student behavior
Prompts and Questions
Teaching Points
Why is N/G tube being continued?
Complete assessment
What is abnormal on CBC and BMP?
Interpretation of Labs
What developmental strategies are
appropriate for this child to learn
about pain control and his care?
Teaching in relationship to statement
of “Wanting it out.”
Incorporate age appropriate
developmental strategies for
distraction and teaching about disease
process and recovery.
Address pain- Last pain med given at
7:00am
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Date/Time
Subjective and Objective Data
Minimal Expected Student behavior
Prompts and Questions
Teaching Points
Physician Makes rounds at 9:00 AM
Wants Lab results
New orders:
Why is the physician changing IV
fluids?
Change IV to D5 1/2NS with 20 mEq
of KCL/L to infuse at 60cc/hr.
Repeat CBC and BMP in AM.
July 21, 2007
Time 4:00pm
4:00 PM Vital Signs and Assessment
HR-88
RR-18
T-99.0
BP-100/68
Student should notify physician of
improvement.
Physician in to see pt.
ABD- Faint BS in all 4 quads.
Decreased distention
N/G- No increase in output
Pt requesting something to drink.
Why & When can we D/C the N/G
and foley?
What is the rationale for starting clear
liquids?
NEW ORDERS:
Discontinue N/G tube and foley
catheter
Bed rest with bathroom privileges
Start ice chips and progress to clear
liquids.
What is important to assess for in this
patient since D/C of N/G and foley?
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Pediatric Simulation--Child with Appendicitis

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