1 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. 2 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 ° 3 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? 5 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 6 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 7 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. 8 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 9 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? 10