Scenario Title
Patient Name
Medical Record #
Level (year 2,
second term)
Author , w/email
Keywords - Theory
Keywords - Skills
Allergic Reaction – Post – Op appendectomy
Nathan Smith
DOB:
NUR 211
Course:
Age:
Marilyn McGuire-Sessions, RN, MSN & Maureen Harter, RN, BSN
Gastrointestinal, Respiratory, Anaphylactic Reaction
Post op care, medication administration IVP, IVP
30 y/o male patient admitted to ED with severe RLQ pain diagnosed as
appendicitis – CT reveals a bulging mass in the area of the appendix. Patient is
status post appendectomy – OR report states the appendix was large, inflamed
and close to bursting. Patient is admitted to 4th floor from PACU. VSS, febrile at
38.1 C , Received Morphine Sulfate 5 mg IV in PACU – reports pain at a “3” prior
to transport out of PACU.
Patient
Case
History:
.
Medical
history:
Allergies:
Meds:
No remarkable medical history. Patient is healthy. This is his first hospitalization.
VS:
BP
Labs:
HR
126/72
82
WBC count 18,000
Height:
NKA
none
RR
16
T
6’3”
38
Weight:
SpO2
230
97
Physician Orders: (Dr. William Steaman) for Nathan Smith DOB – 11-10-75 (age 30)
Allergies - NKA
1. Admit to ACU
2. DX: Appendectomy
3. IV NS with 20 mEq of KCL at 150cc/hr
4. NPO
5. Morphine sulfate 2-3 mg IV push q 1-2 hrs prn pain
6. Phenergan 12.5 - 25 mg IV q 4-6 hours PRN nausea
7. Zosyn 3.375 q 6hr IVPB
7. IS 10 x q 1 hr WA
8. Maintain SpO2 > 95%
9. Notify Physician: SPB >140<80, DBP >90<50; HR>120<50; RR>22<8; T>38.5; UOP <30
cc/hr x 8 hours
Initial Computer Set Up
VS:
BP
Lungs:
Heart:
Ectopy:
Other:
Report to
start
scenario:
124/70
HR
Lt:normal
80
RR
Rt:normal
16
T
37.8
Bowel
sounds
SpO2
97
hypoactive
Rhythm:
Waiting:
“Patient’s vital signs are stable. Abdominal dressing and penrose drain in place
with moderate amount of drainage. Unable to do surgery laparascopically due to
abscess therefore has a larger incision. Patient has not voided since surgery.
Gave 5mg morphine in PACU for pain. Patient was held in PACU due to delay in
transport so patient is due for more pain medicine and has an order for 4 – 5 mg IV
push every1-2 hrs. Since patient was rushed to surgery after findings of the CT
showed an appendix that looked ready to rupture so the pre-op antibiotic was not
administered. Will need to hang the Zosyn as ordered ASAP.
Priorities (in order)
Vital Signs, dressing, pain,
output,
Prepare to hang Zosyn
SN Interventions
Correct Assessment of postop patient, Vitals signs, mark
and initial drainage on
dressing, assess for pain.
Hang Zosyn using 5 rights
and proper technique. Know
to administer over 30 minutes,
potential drug interactions and
side effects to look for.
Patient Responses
Can I have more pain medicine.
What is that?
Explain to patient (Nathan
Smith ) what is being hung
and why.
Assess for degree of pain.
Prepare to give Morphine IV
push
Administer Morphine IV push
If asked – my pain is at a 7 on a
scale of 1-10
Dilute 4 or5 mg Morphine in
4-5 ml sterile water.
Give morphine IVpush using
correct technique ( see skills
lab handout)
Can I have a sip of water my
throat is really scratchy!
Critical thinking of caring for
patient with anaphylactic
reaction.
STUDENT STOPS
ANTIBIOTIC!
Re assess VS,
Puts on O2
Calls Physician, has vitals
signs, SpO2 results ready to
report.
Knows meds that are
normally used in anaphylactic
reaction and locates them
(epinephrine,
diphenhydramine).
Its hard to swallow
What are these red bumps all
over me.
I am starting to itch all over
Physician: Dr Steaman orders:
O2 at 4 L per NC
.5ml epinephrine 1:1000
solution SC, and
Diphenhydramine 50mg IV, and
transfer to ICU
Depending on the actions of the
student :
Simmman starts to have trouble
breathing.
Change lung sounds to
crackles, wheezing, and
diminished lung sounds.
Increase pulse to 100,
decrease BP to 100/60,
decrease PO2 to 90
Simmnan continues to have in
creased trouble
breathing.,continue to increase
pulse and decrease BPand
decrease PO2 depending on
response of student.
Faculty Notes (theory, medications, etc.) For Nathan Smith
1. Meds
a.Zosyn – give over 30 minutes, do not use with lactated ringers, aminoglycosides, heparin.
b. epinephrine –
c. diphenhydramine (benadryl) when given IV do not infuse over 25mg per minute)
2. Adminstration of IV push meds – see skills lab handout
Debrief Priorities (facts, feelings, behaviors, priorities, noticing, interpreting, responding,
evaluating and reflecting-what went well, what would you do differently)
1. Administration of IV push meds
2. S/S of anaphylactic reactions
3. Prioritize steps to take in caring for the patient having an anaphylactic reaction.
4. Phenergan andEpinephrine ( Promethazine may block or reverse effects of epinephrine )
Possible Increased Complexities for this scenario:
1.
References:
1.
Suggestions for Future Advanced Scenarios:
1.