NURSING GRAND ROUNDS
Kelly Wiggins
3/5/15
N421
INTRODUCTION TO PATIENT
• S.G. is a 9 (almost 10) year old male admitted to CHKD with
RLQ abdominal pain
• He c/o nausea and vomiting for 4 days prior to admission,
lethargic 7 days prior, and anorexia for 2 days prior
• Diagnoses with ruptured appendix
• admitted to CHKD on 1/24/15 and scheduled to undergo
emergent appendectomy surgery
• Other medical history-asthma
HOSPITALIZATION
COMPLICATIONS-TIME TABLE
• Appendectomy 1/24/15
• Abcess develops
• Drain placed 1/30/15
• Purulent drainage from appendectomy site
2/4/15
• Incision an drainage performed 2/5/15
RUPTURED APPENDIX
• A ruptured appendix often results from Appendicitis
• Appendicitis -acute inflammation of the appendix
• Occurs when the lumen of appendix is obstructed
• Infection results as bacteria invade the appendix wall
• Mucosa secretes fluid, causing increase in internal
pressure and a blood flow restriction
• Symptoms-abdominal pain, nausea, vomiting, and
anorexia
• CT scan for diagnosis
• Appendectomy as treatment
APPENDECTOMY AND FURTHER
COMPLICATIONS
• An appendectomy, or a
removal of his appendix,
was done on 1/24/15.
• One incision in RLQ
• Abcess formed after
appendectomy (RLQ)
• Drainage tube placed
1/30/15
INCISION AND DRAINAGE
• On 2/4/15, incision site draining large amounts of
purulent fluid
• Incision and drainage scheduled and performed on
2/5/15
• Throughout the day, the wound dressing remained
dry and intact, with minimal drainage
• S.G. developed post-op fever (39.3) that was gone
by the end of the day
CULTURE/CONCERNS THAT
IMPACTED CARE
•Hospitalized for 12 days
•3 surgeries in that time
•Not in usual setting
•Regression
•Not normal behavior according to
mom
DEVELOPMENTAL STAGE
Piaget-Concrete Operational Stage (712 year olds)
• -The
child should be able to reason logically with concrete
things and be able to add and subtract. He should
understand conversation.
• Patient met theoretical developmental stage norms
DEVELOPMENTAL NORMS OF A 10
YEAR OLD
• Likes mother and wants to please her
• Demonstrates affection
• Is successful in looking after own needs
• Can use factitive words (think, know, believe)
• Forms grammatically correct sentences
• Can use telephone for practical purposes
• Responds to advertising/television
• Enjoys conversation
• Slow height increase, rapid weight increase
ASSESSMENT DATA
Respiratory
• wheezing bilaterally
• dyspnea on exertion
• Pt on O2 sat monitor
Integumentary
• incision RLQ
• dressing clean, dry, intact
GastroIntestinal
• incision site RLQ
covered with dressing
• pain at incision site
3/10
Pain
• 3/10-4/10
throughout day
Musculoskeletal
• needs assistance with ambulation
& when being transferred
• strength x1 in lower extremities
• pt unable to stand up on own
Psychosocial
• mom only at bedside for 1
hour in 2 days
• pt calls mom by her name
and not “mom”
• regression
NURSING DIAGNOSIS 1
INFECTION
Infection related to appendectomy as evidenced by
• WBC count 15.5 (2/3/15)
• Purulent drainage from appendectomy incision site
• Abscess formation RLQ
• Culture positive for E. coli and S. Pneumoniae bacteria
• Medications-piperacillin-tazobactam (Zosyn)
• Abscess developed in RLQ (Drained 2/5/5 via I&D
• Post op day 12 for appendectomy, post op day 6 for
drainage tube insertion of abscess, PICC line
INTERVENTIONS
• Assess WBC count, temperature daily
• Administer Antibiotics as prescribed, on time
• Promote increased fluid and nutrient intake
• Assess incision site for drainage color, amount, odor
• Teach patient about hand washing and proper hygeine
EXPECTED OUTCOMES AND
EVALUATION
Expected Outcomes
• Within one week the WBC count will reach normal limits, pt
will learn ways to prevent infection spread, and incision site
will be free of drainage.
Evaluation
• pt. WBC count down to 12.2 on 2/5 (down from 20.4 on
1/29/15, pt verbalized the importance of washing hands
NURSING DIAGNOSIS 2
IMBALANCED NUTRITION: LESS THAN
BODY REQUIREMENTS
• Hx of nausea/vomiting 4 days prior to admission
• Hx of anorexia for 2 days prior to admission
• Weight drop from admission weight (admission weight 28.7 kg and weight on
2/5/15 25.9 kg)
• Pt fatigued and weak (strength in extremities x1)
• Decreased caloric consumption
• Pt wouldn’t eat after TPN was discontinued
• 5th percentile on the growth chart for weight on 2/5/15
INTERVENTIONS
• Teach patient why he needs increased fluid and caloric consumption
• Offer small frequent meals instead of large meals 3 times
• Control pain prior to meal times
• Monitor weight daily
• Teach family to encourage him to eat
• Find out food preferences
EXPECTED OUTCOME AND
EVALUATION
• Expected outcomes-patient will eat ¾ of meals
throughout the day and drink 1 full pediasure,
progressing to eating full meal in 5 days.
Evaluation
• On 2/5/15 pt. ate two full meals, but didn’t drink
any pediasure
NURSING DIAGNOSIS 3
FATIGUE
• Related to decreased caloric consumption
• History of lethargy, anorexia, and nausea/vomiting
before admission
• Pt complaint of nausea when eating, not eating full
meals or drinking pediasure as ordered
• RBC count 3.27 (2/3/15) Hgb 9.4 (2/3/15) Hct (28.7%)
• Anemia
INTERVENTIONS
• Encourage proper rest, no distractions, calm environment
• Encourage proper caloric intake and consumption of meals and pediasure
• Assess fatigue level before performing activities that are not critical
• Allow patient to take his time with ambulation, repositioning-don’t make him
feel rushed
EXPECTED OUTCOME AND
EVALUATION
• Patient will verbalize that he has more energy and is
less fatigued after consuming 3 meals/pediasure
and resting quietly in bed
Evaluation
• Patient had 2 full meals, no physical activity
throughout the day, is still very fatigued
NURSING DIAGNOSIS 4
ACUTE PAIN
Related to abdominal surgery (appendectomy and
incision & drainage)
• Reports pain 4/10 consistently throughout day at
incision site
• Facial grimacing when anyone goes near
dressing/incision site
• Acetaminophen/hydrocodone po q6h prn
• Morphine IV drip
INTERVENTIONS
• Assess pain q4h using pain scale
• Administer pain meds before pain becomes
unbearable and assess for effectiveness (30 minutes
after for Acetaminophen-hydrocodone)
• Determine any alleviating/worsening factors
affecting his pain
EXPECTED OUTCOMES AND
EVALUATION
• Patient will report pain <3/10 on pain scale
throughout the day and will ask for prn pain meds
before pain > 5/10
Evaluation
• Pain stayed around a 4/10 throughout day, pt verbalized
when he was in pain and needed prn meds, but said
4/10 was tolerable for him
NURSING DIAGNOSIS 5
KNOWLEDGE DEFICIENT-PARENT
• Patient has hx of asthma, but mother continues to
smoke around him
• Mother not at bedside for more than 2 hours
• She didn’t know what kind of surgery he had that
morning (I&D)
• Mother didn’t know/understand why fluid and
caloric intake was so important
INTERVENTIONS
• Teach mother about patients condition
• Allow her to ask questions and be receptive to them
• Do not judge mother for knowledge/lack of knowledge, she
needs to feel comfortable when discussing the patient
• Carefully explain everything being done to the patient while
its being done so she can see it
EXPECTED OUTCOME
• Mother will take active participation in care of patient and learn
about his hospitalization, asking questions when need be
• Mother will be able to verbalize back to nurse the importance of
her son intaking the proper amount of fluid/nutrients
• Evaluation
• Mother left bedside after brief interaction with patient-said she now
understands the reason for increased caloric demand/necessity
TYING IT ALL TOGETHER
Imbalanced
Nutrition
Infection
Fatigue
Acute
Pain
Knowledge
Deficit
CARE GIVEN
• Nutritional support- TPN post-op (DC’d), Pediasure
• Medications - Piperacillin-tazobactam,
Acetaminophen-Hydrocodine, Morphine, Zofran
• Play therapy
TEACHING AND DISCHARGE
PLANNING
• Patient teaching needs
• Dressing and incision site
• Fluid and caloric consumption
• Infection control
• Parent teaching needs
• Information about patient
hospitalization
• Caring for patient at home
• Encouraging increased fluid and
caloric intake
• Play therapy
Discharge Planning
• Patient will need to complete
antibiotics prior to discharge (IV)
• Mother should monitor for signs
of worsening infection once
discharged
• Monitor for further abscess
formation
• Instruction of caring for incision
site prior to discharge
NURSING RESEARCH
• The use of non-pharmacological methods for children’s postoperative pain
relief
• Examined nurses use of non-pharmacological methods for school-aged
children’s post op pain relief
• Surveyed 134 RN’s in Singapore using questionnaires
• Results showed that methods like relaxation techniques and breathing
techniques were used most often, with massage and thermal regulation being
used least often
• Only 58% reported frequently using preparatory information, or telling the patient
what to expect before doing any procedure
SUMMARY AND CONCLUSION
• S.G. 9 year old patient with ruptured appendix
• Appendectomy -> abscess -> incision and drainage
• Developmental considerations
• Concept map discussion with expected outcomes and evaluation
• Teaching and discharge planning
• Research article
QUESTIONS?
REFERENCES
• Hockenberry, M. J., & Wilson, D. (2011). Wong's nursing care of infants and
children (9th ed.). St. Louis, MO: Mosby/Elsevier.
• He, H., Lee, T., Sinnappan, R., Vehvilainen-Julkunen, K., Polkki, T., &
Ang, E. (2011). Use of nonpharmacological methods in children's
postoperative pain relief: Singapore nurses' perspectives. Journal for
Specialists in Pediatric Nursing, 16(1), 27-38.
• Ignatavicius, D. D. (2011). Medical-surgical nursing: patient-centered
collaborative care(7th ed.). St. Louis, Mo.: Saunders/Elsevier.