Appendicitis/Appendectomy
SKINNY Reasoning
Suggested Answer Guidelines
John Washington, 14 years old
Primary Concept
Inflammation
Interrelated Concepts (In order of emphasis)
•
•
•
•
NCLEX Client Need Categories
Pain
Stress
Clinical Judgment
Patient Education
Percentage of Items from Each
Category/Subcategory
Safe and Effective Care Environment
✓ Management of Care
✓ Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
✓ Basic Care and Comfort
✓ Pharmacological and Parenteral Therapies
✓ Reduction of Risk Potential
✓ Physiological Adaptation
Covered in
Case Study
17-23%
9-15%
6-12%
6-12%
✓
6-12%
12-18%
9-15%
11-17%
✓
✓
✓
✓
✓
✓
0
SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
John Washington is a healthy 14-year-old African American male who weighs 150 lbs. (68.2 kg). He came to the
emergency department because he woke up this morning at about 2 am with "excruciating" generalized abdominal pain
around his belly button that has been progressively getting worse over the past several hours. It is now 2 pm. He took
ibuprofen 400 mg PO this morning, which decreased the pain some but is now more painful and uncomfortable. The pain
is now localized to his RLQ. The pain increases with walking and movement but he feels better when he lies down in a
fetal position. He vomited three times after he drank some orange juice for breakfast this morning and has had nothing to
drink since. He continues to feel nauseated but has not had an emesis since this morning.
Personal/Social History:
John lives with his mother and three younger brothers. He is active in athletics and has a strong social network of friends
and family in the inner-city neighborhood where he lives.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Woke up this morning at about 2 am with
"excruciating" generalized abdominal pain
the past several hours that has been
progressively getting worse.
Clinical Significance:
Pain is a clinical RED FLAG, especially when there is no prior history.
Sudden onset of pain that is severe and becomes gradually worse makes
this complaint even more concerning.
He took ibuprofen 400 mg PO this morning,
which decreased the pain some but is now
more painful and uncomfortable.
The pain is now localized to his RLQ.
Took an adequate dose of pain medication that did relieve the pain
temporarily.
The pain increases with walking and
movement but feels better when he lies down
and lies in a fetal position.
This is a classic clinical RED FLAG for appendicitis. The appendix is
located in the RLQ. Early appendicitis tends to be generalized pain, but
over time the pain becomes localized and is focused right where the
inflammation is present. There is no one uniform set of symptoms for
appendicitis; however, that migratory pain is a consistent symptom of
acute appendicitis
Inflammation from the appendix causes irritation/inflammation of the
peritoneum. If appendicitis is the present problem, movement of any kind
tends to worsen the pain, while lying quietly relieves the pain.
RELEVANT Data from Social History:
He is active in athletics and has a strong
social network of friends and family in the
inner-city neighborhood where he lives.
Clinical Significance:
No concerns present, but relevant to note that he has a strong social
network to draw strength and support from.
Patient Care Begins:
Current VS:
T: 100.5 F/38.1 C (oral)
P: 106 (regular)
R: 20 (regular)
BP: 142/76
O2 sat: 99% RA
P-Q-R-S-T Pain Assessment:
Movement, palpation
Provoking/Palliative:
Sharp, cramping
Quality:
Mid abdomen, RLQ
Region/Radiation:
8/10
Severity:
Continuous
Timing:
1
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:
T: 100.5 F/38.1 C (oral)
Clinical Significance:
Low-grade temperature present. This is consistent with the activation of the inflammatory
response. Clinical RED FLAG! The inflammatory response is being activated for a reason!
P: 106 (regular)
HR is elevated. The nurse must determine why. Temperature is too low to cause this degree
of HR elevation. The most likely reason is the amount of pain he is c/o
BP: 142/76
Is higher than normal. Pain is the most likely reason
Pain 8/10, sharp,
cramping, continuous in
RLQ
Pain is the fifth VS and is always relevant. 8/10 is severe pain and it’s continuous. It is there
for a reason. This degree and location of pain are consistent with appendicitis.
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):
Abdomen/GI
PRIORITY Nursing Assessments:
Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes)
• Contour – (flat, rounded, scaphoid, protuberant/distended)
• Umbilicus – contour
• Symmetry (relaxed, supine position)
• Abdominal movement during breathing
Auscultation: (completed before palpation/percussion to not alter bowel sounds)
• Bowel sounds – 1 minute per quadrant with the diaphragm
• Intensity, pitch, frequency
Palpation:
• Light palpation to all quadrants – 1 to 2 cm to detect tenderness
• Assess for rebound tenderness-pain that increases when fingers removed
quickly from abd
• Palpate bladder- light palpation ONLY; you only want to assess to see if it
is distended
Current Assessment:
GENERAL SURVEY:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
INTEGUMENTARY:
Alert, oriented, pleasant, appears tense, uncomfortable, dress appropriate for the season,
hygiene and grooming normal for age and gender.
Alert & oriented to person, place, time, and situation (x4)
Head normocephalic with symmetry of all facial features. PERRLA, sclera white
bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and
moist.
Breath sounds clear with equal aeration on inspiration and expiration in all lobes
anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air.
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 S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs.
Abdomen round, rebound tenderness in RLQ to gentle palpation. Rebound tenderness
present in RLQ, BS + in all four quadrants, bowel sounds diminished/hypoactive
Voiding without difficulty, urine clear/dark amber
Skin warm, dry, intact, normal color for ethnicity. Cap refill <3 seconds. Hair soft-
2
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:
GENERAL SURVEY: Appears tense,
uncomfortable
Clinical Significance:
His nonverbal body language communicates that he is uncomfortable and in
pain, as he reports he is.
ABDOMEN: Abdomen round,
tenderness in RLQ to gentle palpation.
Rebound tenderness present in RLQ.
Rebound tenderness in RLQ is another clinical RED FLAG for appendicitis.
Rebound tenderness, or pain when the hand is quickly removed after
palpation is caused by peritoneal irritation. McBurney's point, located twothirds of the distance between the umbilicus and the anterior superior iliac
crest, typically overlies the appendix and is, therefore, the point of maximal
tenderness.
GU: Voiding without difficulty, urine
clear/dark amber
The remainder of the nursing assessment is unremarkable and WNL.
Dark amber urine is consistent with concentrated urine and dehydration.
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
Clinical Significance:
This confirms the clinical cues that have been collected to this point that suggest
appendicitis.
Results:
Enlarged, non-compressible
appendix
Lab Results:
Current:
WBC
14.5
Complete Blood Count (CBC)
HGB
PLTs
15.2
245
% Neuts
88
Bands
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:
These labs are ALWAYS
RELEVANT, therefore
they must be intentionally
noted by the nurse!
WBC: 14.5
• ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection
• Usually increased if infection present. Consistent with the problem of known appendicitis.
Hgb: 15.2
• ALWAYS RELEVANT to determine anemia or acute/chronic blood loss. No problem
present.
Platelets: 245
• Relevant whenever there is a concern for anemia or blood loss or a patient on heparin
• WNL. He will be going to surgery, so an adequate level of platelets for clotting needs to be
noted.
• If platelets are low, it will be significant and must be noted.
3
•
•
•
•
Neutrophil %: 88
• Immature neutrophils that are elevated in sepsis as the body attempts to fight infection and
releases these prematurely
• If elevated, it’s a clinical RED FLAG in the context of sepsis. If elevated to >8, it is
considered a “shift to the left,” which indicates impending sepsis.
Bands: 0
Current:
ALWAYS RELEVANT for the same reason as WBCs
Elevation confirms the presence of inflammation or infection
Most common leukocyte
FIRST RESPONDER to any bacterial infection within several hours or when the
inflammatory response is activated
Basic Metabolic Panel (BMP)
K
Gluc.
3.5
95
Na
133
Creat.
0.9
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:
These labs are ALWAYS
RELEVANT, therefore
they must be intentionally
noted by the nurse!
All labs in BMP WNL. Ensure that students understand the physiologic significance of
each of these labs. Knowing that it is normal is not enough!
Sodium: 133
• Sodium is borderline/normal, but needs to be noted by the nurse.
• I consider Na+ the “Crystal-Light” electrolyte. Though this is simplistic, it does help to
understand in principle how basic Na+ is to fluid balance
• When you add one small packet of Crystal Light to your 16-ounce bottle of water, the
concentration is just right. This is where a normal Na+ will be (135-145)
• Where free water goes, sodium will follow to a degree. Therefore if there is a fluid volume
deficit due to dehydration, Na+ will typically be elevated because it’s concentrated (less
water)
• If there is fluid volume excess, Na+ will be diluted and will likely be low. It is the
“foundational” fluid balance electrolyte!
Potassium: 3.5
• Lab is normal, but needs to be noted by the nurse.
• Essential to normal cardiac electrical conduction, as is Mg+
• If too high or low can predispose to rhythm changes that can be life threatening!
Glucose: 95
Creatinine: 0.9
•
•
•
•
Lab is normal, but needs to be noted by the nurse.
Required fuel for metabolism for every cell in the human body, especially the brain
Relevant with history of diabetes or stress hyperglycemia due to illness
Elevated levels post-op can increase risk of infection/sepsis.
• Lab is normal, but needs to be noted by the nurse.
• GOLD STANDARD for kidney function and adequacy of renal perfusion
• The functioning of the renal system affects every body system; therefore, it is ALWAYS
relevant!
.Misc.
Current:
Lactate
4.1
CRP
55
4
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:
The following lab values
are WNL, but they are
ALWAYS RELEVANT and
must be intentionally
noted by the nurse!
•
•
•
•
Lactate: 4.1
C-Reactive Protein
(CRP): 55
Remember Krebs cycle and lactic acidosis in A&P due to anaerobic metabolism?
GOLD STANDARD lab to trend with any shock state, especially sepsis!
Lactate as high as 4.5 can be expected for acute appendicitis without a perforation.
Lactate builds up within the serum and can be seen as a marker of strained cellular
metabolism
• CRP is a nonspecific systemic inflammatory marker and has a high sensitivity to
differentiate between patients with and without appendicitis, thus can be used to support
the clinical diagnosis of appendicitis.
• CRP levels can be used to support the clinical diagnosis of appendicitis and depending on
time from onset of symptoms to diagnosis, CRP levels can also be used to differentiate
patients with and without appendicitis.
• Measurement of C-reactive protein is useful in the diagnosis of acute appendicitis, mainly
in cases with more than 12 hours of evolution. The combined tests improved the predictive
values.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
(Reduction of Risk Potential/Physiologic Adaptation)
Lab:
WBC
Normal
Value:
4,500-11,500
or
(4.5–11.0 mm 3)
Value:
14.5
Critical
Value:
<2,500 or
>15,000
Clinical Significance:
Nursing Assessments/Interventions Required:
Confirms the presence
of infection and degree
of elevation provides a
baseline of the degree
of
infection/inflammatory
response. Must be
trended daily to see
direction is heading
clinically.
THINK INFECTION
*Assess for tachycardia and hypotension with known
infection (Tachycardia EARLY sign of septic shock)
*Assess closely for any change in temperature trendhypothermia or febrile can both represent sepsis, especially
in elderly patients.
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Part II: Put it All Together to THINK Like a Nurse!
1. Interpreting relevant clinical data, what is the primary problem? What primary health-related concepts does this
primary problem represent? (Management of Care/Physiologic Adaptation)
Problem:
Pathophysiology of Problem in OWN Words:
Primary Concept:
Appendicitis
Appendicitis is defined as an inflammation of the inner lining of the vermiform
appendix that spreads to its other parts. Appendicitis is caused by obstruction of
the appendiceal lumen from a variety of causes including infection and
constipation. Obstruction is believed to cause an increase in pressure within the
lumen. Such an increase is related to continuous secretion of fluids and mucus
from the mucosa and the stagnation of this material. At the same time, intestinal
bacteria within the appendix multiply, leading to elevation of white blood cells
and formation of pus that causes higher intraluminal pressure within the appendix
that can cause it to burst if left untreated. (Craig, 2018)
Inflammation
Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies)
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Care Provider Orders:
Establish peripheral IV
Rationale:
Will require IV medications, IV fluids, and surgery!
0.9% NS 1000 mL IV bolus
Isotonic fluid to provide hydration
Morphine 2 mg IV every 2
hours PRN
Expected Outcome:
IV established
Adequate hydration
status
Opioid narcotic to decrease pain. Reinforce time action profile with Pain
students. Onset 15” Peak 30” Duration 4 hours. Assess response to controlled/decreased
pain meds at peak! Dose is safe and intermediate.
Ondansetron 4 mg IV every
4 hours PRN nausea
Strong antiemetic used with cancer patients who experience severe
nausea. Dose is standard
Nausea
controlled/decreased
Ceftriaxone 1 g IVPB x1
now
Antibiotic prophylaxis should be administered before every
appendectomy. Cephalosporins are the best choice. Exhibit
bactericidal activity by the inhibition of bacterial wall synthesis.
Infection/sepsis
prevented
Metronidazole 500 mg IVPB
every 12 hours
Antibiotic prophylaxis should be administered before every
appendectomy. Metronidazole has broad gram-negative and
anaerobic coverage and is used in combination with
aminoglycosides (eg, gentamicin). This drug appears to be
absorbed into cells; intermediate metabolized compounds bind
DNA and inhibit protein synthesis, causing cell death (Craig, 2018)
Infection/sepsis
prevented
General surgeon consult
Appendectomy remains the only curative treatment of appendicitis.
Surgical
intervention
facilitated
Strict NPO
Prevent aspiration in surgery with intubation and avoid worsening
inflammation already present
NPO status
maintained
6
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
• Pain control
Nursing PRIORITY:
•
Prepare for surgery
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome:
Pain Control
Morphine IV PRN
Opioid narcotic to decrease pain.
Pain controlled
Reinforce time action profile with students. Onset
rapid, Peak 20” Duration 4-5 hours. Assess
response to pain meds at the peak! The dose is safe
and intermediate.
Adequate pain control
at peak
Prevent aspiration in surgery with intubation and
avoid worsening inflammation already present
NPO status
maintained
Initiate preop orders/have consent in the
chart
Is not a nursing responsibility to have patient (or in
case of a minor, the parent/legal guardian) to sign
the consent until the surgeon has met with the
family. But be sure is in the chart to facilitate once
the patient is brought to PACU.
Preop orders
implemented and
consent in the chart
Provide essential preop/postop teaching
to patient and family of what to expect
Assess what patient/family knows about surgery.
Explain the difference between laparoscopic
surgery and open laparotomy. Laparoscopic is
preferred unless there is a problem during surgery.
Reinforce what to expect before surgery and basic
postop care.
Teaching completed
Answer questions. Support as needed
Be available to answer questions to support the
patient as well as decrease fear and anxiety that are
likely present. As an adolescent, most of the
teaching and explanations should be focused on the
patient. However, in family-centered care, nurses
want to include parents as part of the discussion
and are sure to answer and address questions they
have as well.
Questions answered
anxiety decreased
Assess response to pain medication
including pain rating, VS and LOC
Prepare for Surgery
Maintain strict NPO
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES:
PRIORITY Nursing Interventions:
CARE/COMFORT:
Caring/compassion as a nurse
Use your lens of practice as an educator to determine how you would
establish a plan of care for each of the psychosocial priorities identified
above. I have some general recommendations below that can be used to
initiate dialogue and discussion.
Rationale:
Expected Outcome:
Discuss the following principles to effectively
engage and communicate caring by showing that
Will feel valued and
the patient matters to the nurse:
comforted
Emotional support
BE PRESENT and AVAILABLE to your patient.
When this is made intentional to your patient, it
communicates caring (Swanson, 1991).
7
When providing a plan of care or a teaching
strategy, nurses need to consider where the child is
developmentally using theorists such as Erikson.
Piaget and Kohlberg. Adolescents are seeking
independence so they may, or may not be willing to
participate in care. He may also be concerned about
body image or appearance because of the surgery.
Will feel valued and
The nurse should explain things logically. He may
comforted
or may not want his mother present.
Providing/offering hope
Hope is related to meaning and purpose in life, but
its emphasis is on having a future hope or
expectation. This is closely related to spiritual care
(Swanson, 1991).
This is always relevant. As an adolescent, this
patient’s responses will be close to those of an
adult. As a 14-year-old he may experience the
gamut emotionally from high to low. He is described
as a positive and confident young man. That is
typical, but he can quickly bounce to lack of
confidence. He is likely to be moody and possibly
even depressed and also will experience frustration
from being away from his peer group
Also as a teen, he is better able to express feelings
through talking (he may not talk much although preop). Because he is capable of more complex
thought, he will be able to understand teaching.
(That said, let’s keep it simple and health literacy
sensitive). Also at this age, he has a strong sense of
right and wrong.
In relationship to moral development, a 14-year-old
would be in a conventional stage with a law and
order orientation. Throughout the conventional
level, a child’s sense of morality is tied to personal
and societal relationships. Children continue to
accept the rules of authority figures, but this is now
due to their belief that this is necessary to ensure
positive relationships and societal order. Adherence
to rules and conventions is somewhat rigid during
these stages, and a rule’s appropriateness or
fairness is seldom questioned.
This means that he would obey rules because it is
what he is supposed to do to function in society.
Physical comfort measures
Nurse Engagement
The nurse must remain clinically curious and
responsive to the patient’s story and situation. When
distracted and not engaged, the nurse will be unable
to invest the energy needed to recognize relevant
and urgent clinical signs that may require
intervention. When nurses are not engaged with the
patient and their clinical problem, patient outcomes
8
will suffer.
It is easy to get distracted or to focus on just one or
two glaring items which may prevent the nurse from
seeing the bigger picture (this often happens with
the students). They need to learn to recognize
seemingly isolated factors and discover how they
are all part of the whole puzzle. This is one of the
biggest challenges that the students face.
Nurse Presence
To be present means that the nurse is AVAILABLE
and ACCESSIBLE and this is communicated to the
patient. Presence can also be defined as “being
with” and “being there” to meet their needs in a
time of need. Other ways to define or explain
presence include caring, nurturance, empathy,
physical closeness, and physical touch. (Rex–Smith,
2007).
Similarly, when nurses practice true presence, they
can determine what's most important to patients by
listening to what they say, what they don't say, and
how they describe things that were done, and by
noting nonverbal feedback such as facial
expressions, gestures, and silences. With this
information, nurses can facilitate health by
introducing new possibilities that may help patients
enhance their quality of life. This therapeutic use of
self allows nurses to intuitively understand how to
deliver effective and satisfying care with both
creativity and style.
Use of touch
Touch is a fundamental human need and an
appropriate intervention that nurses should
integrate into their practice. Touch is a positive way
to influence the patient’s physical environment. It
uses nature to influence the patient’s well-being
(Bush, 2001).
EMOTIONAL (How to develop a
therapeutic relationship):
Discuss the following principles needed
as conditions essential for a therapeutic
relationship:
• Rapport
• Trust
Never underestimate the power of the “little things’
that are done for your patients. I have observed that
the little things such as basic hygiene, shave, back
rub, or obtaining the patient’s story, are the BIG
things that communicate caring and also make them
feel so much better!
In pediatrics, the relationship has to be familycentered and should include the child, the parents
and any other family members who might be
present. The very first process between nurse and
client is to establish an understanding in the client
that the nurse is entering into a relationship with the
client that essentially is safe, confidential, reliable,
and consistent with appropriate and clear
9
•
•
•
Respect
Genuineness
Empathy
SPIRITUAL:
• F-Faith or beliefs: What are your
spiritual beliefs? Do you consider
yourself spiritual? What things do
you believe in that give meaning to
life?
• I-Importance and influence: Is
faith important to you? How has
your illness or hospitalization
affected your belief practices?
• C-Community: Are you connected
to a faith center in the community?
Does it provide support/comfort for
you during times of stress? Is there a
person/group who assists you in your
spirituality?
• A-Address: What can I do for
you? What support can healthcare
provide to support your spiritual
beliefs/practices?
CULTURAL Considerations
(IF APPLICABLE)
boundaries.
With a 14-year-old, the nurse would do this directly
with the patient, taking into consideration that
potential moodiness might impede the development
of a therapeutic relationship. With younger
children, the nurse establishes rapport and trust
with the parent first, and as the child sees that the
parent trusts the nurse, they will begin to trust the
nurse. About respect: The nurse should consider
the parent to be the expert in the care of his or her
own child. This means asking a parent how they
would provide the care. This is particularly relevant
for children with chronic illnesses. Regarding
genuineness: In pediatrics, you’d better be genuine,
because kids can see right through you if you aren’t.
These questions, if used in this scenario by the
nurse, would naturally explore this patient’s
spirituality. It is always best if the nurse has some
comfort in the exploration of spirituality. Patients
can sense discomfort or anxiety in approaching this
portion of the assessment. The FICA model offers
some open-ended questions to make spiritual
assessment a natural part of the conversation. Use
this spiritual assessment tool to make caring for the
spirit an essential component of your nursing
practice!
Faith/beliefs are
supported
Students will ask if they can be in prayer for the
child. Even in the midst of preparing a child for
surgery, parents are comforted knowing that the
nurses care about more than the child’s
physiological needs, but also the emotional and
spiritual needs.
Since religious worldviews provide a window to the
prevailing values and ethnic norms of any cultural
group, knowledge, and understanding of the most
dominant religions of ethnic groups in your
community are essential and will facilitate cultural
sensitivity. But remember that there will always be
exceptions, so be careful not to make assumptions!
Becoming knowledgeable about another cultural
group and integrating this knowledge into your
practice is the essence of becoming culturally
competent. It means respecting each patient’s
cultural diversity and examining how their beliefs
may affect their health care. When nursing care
does not intersect with the patient’s worldview or
belief set, compliance with the proposed treatment
plan will be less likely (Ward, 2012).
Cultural beliefs are
supported by meeting
a person where he or
she is, rather than
expecting them to
comply with the
nurse’s beliefs or
values.
10
Education Priorities/Discharge Planning
5. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family?
(Health Promotion and Maintenance)
Education PRIORITY:
Prepare for transition to home
PRIORITY Topics to Teach:
Promote health and prevent
complications
Rationale:
Diet:
Normal diet after surgery.
Bowels sounds/motility have fully
returned
Activity:
Avoid strenuous activity and heavy lifting for the first 1-2 weeks after laparoscopic
surgery, 4-6 weeks after open surgery.
Prevent dehiscence
Wound care:
Surgical incisions should be kept clean and dry for a few days after surgery. Most
of the time, the stitches used in children are absorbable and do not require
removal. Your surgeon will give you specific guidance regarding wound care,
including when your child can shower or bathe.
Assessing for healing and/or signs
of infection which should be
specifically described to the patient
Medicines:
Medicines for pain such as acetaminophen (Tylenol®) or ibuprofen (Motrin® or
Advil®) or something stronger like a narcotic may be needed to help with pain for
a few days after surgery.
Stool softeners and laxatives are needed to help regular stooling after surgery,
especially if narcotics are still needed for pain.
(Take pain meds only as needed to control pain. I do not see stool softeners
routinely given in peds, but it is not inappropriate…at the very least, teaching
should be done about the importance of regular stools once the bowels start
working again. This is closely monitored by the nurses.)
What to call the doctor for:
Call your doctor for worsening belly pain, fever 38.5°C (101oF), vomiting,
jaundice, if the wounds are red or draining fluid, diarrhea or problems with
urinating.
Follow-up care:
Your child should follow up with his or her surgeon 2-3 weeks after surgery to
ensure proper post-operative healing.
Antibiotics
Often the patient will finish the course of antibiotics by going home with PO doses.
Here the teaching needs to include the importance of completing the entire course
of the medication.
Control pain
Potential signs of infection, or
abscess or peritonitis
The physician needs to check
patient to ensure that healing is
progressing as expected.
Prevent resistant organism
development
What additional considerations need to be made when teaching the parents of a pediatric patient?
The nurse needs to consider both the emotional and learning needs of the parents. This involves being truly present, but
it also means listening to them because they are the experts of the care of their child, while at the same time, not letting
their anxiety get in the way of doing what needs to be done for their child. But most of all they need to know that you as
the nurse care about what is happening to their child
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Author
Keith Rischer, RN, MA, CEN, CCRN
Reviewers
•
Marion Dunkerley, EdD, MA, MSN, RN, Assistant Professor Pediatrics, California Baptist University, Riverside
California
•
Linden Fraser, RN, MSN, Nursing Faculty, Nicolet College, Rhinelander, Wisconsin
References
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