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Nursing Case Study: Complicated Appendicitis

Taken from Winningham 5th ed case #109
by

Raquel B

on 10 November 2015

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Transcript of Nursing Case Study: Complicated Appendicitis

Case Study Questions

Identify the clinical manifestations exhibited by R.O. that most clearly reflect the classic presentation of appendicitis
Case Study 109
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Which of these signs of appendicitis did R.O. exemplify?
Discuss why R.O.'s presenting clinical manifestations make diagnosis more difficult; identify two other possible diagnoses.
Viral Gastroenteritis:
Abdominal pain
Diarrhea
Vomiting
Fever
Loss of appetite
Possibility #1
Possibility #2
What symptoms do not concur with appendicitis?
The abdominal CT confirms that R.O. has appendicitis. Which of these orders are appropriate? Explain rationale. If the order is inappropriate, explain why:
1. Make pt NPO
2.Place a peripheral IV and begin D51/2 NS at 80mL/hr
3.Administer Fleet Enema to rule out impaction
4.Administer morphine sulfate 2 mg IV q2h for pain.
5. Obtain surgical consent from patient
6.Administer Cefotaxime (Claforan), a broad spectrum antibiotic at q150 mg/kg/day q6h



1. PT is NPO to prepare for appendectomy. When there is a potential for surgery patients are put on NPO to minimize the risk of aspiration (a complication of general anesthesia). Maintaining an NPO status prevents the inflammation from getting worse and prevents vomiting.

2. IV fluid therapy is started to prepare the child for surgery and correct any existing fluid, electrolyte, and acid-base disturbances related to vomiting and diarrhea (p.1091, McKinney). They also maintain hydration.

3. Enemas should be avoided if appendicitis is suspected. Since they stimulate bowel motility and increase the risk of perforation (p.762, Potts)

4. Pain meds should be administered to help cope with pain and enhance comfort

5. The PT. is 12 yrs old; therefore she cannot legally provide consent. Consent must be obtained by the legal guardian if the patient is not 18 and older (review p.19, Mckinney)

6. Cefotaxime is a 3rd generation Cephalosporin, a broad-spectrum antibiotic that is active against gram positive and gram-negative microorganisms. This medication is given to treat infection of the appendix. Given prophylactically for peritonitis.


Peritonitis. (n.d.). Retrieved from http://studentnurses3.blogspot.com/p/medical-surgical-nursing-mnemonics.html

Lehrer, J. (Ed.). (2014, May 15). Viral Gastroenteritis. Retrieved September 20, 2015, from https://www.nlm.nih.gov/medlineplus/ency/
article/000252.htm

Silvestri, L.A. (2014). Gastrointestinal System. Saunders Comprehensive Review for the NCLEX-RN examination (6th ed., pp. 686). St. Louis,
Missouri: Elsevier.

R.O.'s weight is 42 kg, and height is 155 cm. Calculate her maintenance fluid needs and discuss how this will be met.


Mr. and Mrs. O. give informed consent, and R.O assents to the surgery after the procedure is explained to her. Why is it important for R.O to provide her assent for the procedure?
What should be included in the preoperative teaching for R.O and her parents?
Identify five priority nursing considerations.
Applying Standards:


Calculate fluid maintenance: 42kg-10kg=32kg 32kg-10kg= 22kg

42kg 10x100 mL/kg/day = 1000 mL/day
-10kg
32kg

32kg 10x50 mL/kg/day = 500 mL/day
-10kg
22kg

22kgx20 mL/kg/day = 440 mL/day

Total 1940 mL/day

1940 mL/24 = 80.83 mL/hr

Her maintenance fluid needs are 80.83/hr. Pt. should be given isotonic fluids, such as ringer’s lactate and normal saline to reduce hypovolemia.

The Joint Commission’s NPSG’s:
“Patients deserve to be informed and involved in decisions affecting their health care”
Expressed consent.
Ethical and legal requirement: risks and benefits must be explained
NPO
Assessing knowledge
Answering questions and encouraging communication
Measure I&O
Pain management

Teaching family exercises to promote healing
Promote rest
Explanation of routine care; Vital signs
PACU recovery time

Ignatavicius, D. D., & Workman, M. L. (2013). Medical- surgical nursing: patient-centered collaborative care. St. Louis: Elsevier Saunders.

UPDATE:

R.O. undergoes an appendectomy; the
appendix has ruptured
. The peritoneum is inflamed, and
abscesses are seen near the colon and small intestine
. R.O. is admitted to the surgical unit; she is
NPO
, has a
nasogastric tube (NGT), Foley catheter, IV, abdominal dressing, and a Penrose drain
.
CASE STUDY PROGRESS
Postop Day 2: R.O.
continues to improve
and is tolerating ice chips.
Breath sounds are clear,
and she is performing her pulmonary hygiene.
NGT has minimal drainage
. Foley catheter has been removed, and the patient has
adequate urine output.
The
Penrose drain has been removed
. The
incision is well approximated with no drainage or redness.

Her pain is 4-6 out of 10 with pain medication
every 4 hours.

Postop Day 3: Assessment shows that
R.O. is pale and listless
;
bowel sounds are absent
;
abdomen is distended and tender to the touch
; the
NGT is draining an increased amount of dark, greenish black fluid
.
Her lung sounds are moist bilaterally
, and her temperature has spiked to 40.2° C
(104.4° F)
. She rates
her pain at 10 out of 10 and is having difficulty taking deep breaths
because of the pain, which she says
“hurts over my whole stomach.”

What should your priority nursing care include? 

Using SBAR (situation, background, assessment, recommendation), what would you communicate to the surgeon?
What will you consider as part of your nursing management of RO’s pain?
Quick pain medication administration; recomend increasing does if necessary
Patient positioning: breathing is affected by pain
Observe for S&S of respiratory depression as a result of Opiod use
Ineffective breathing pattern may result in hypoxia and from opiod use
Teach deep breathing and relaxation
What should you consider in your approach to help R.O. cope with the procedure?

Update:
The surgeon assesses R.O. and orders a return to the operating room. R.O. returns to surgery, where she has
lysis of adhesions
,
removal of necrotic bowel
, and
drainage of an abscess
. The surgeon has left her
abdominal wound open
and has ordered wound packing changes twice daily and abdominal irrigation with normal saline (NS).
R.O. cries and becomes agitated when you go to perform the procedure
.
In anticipation of R.O.'s discharge, identify expected outcomes that must be achieved before her leaving the hospital.

- Anxiety
-Level of pain B&A procedure
-Pt’s understanding of the procedure
-Pt fatigue during procedure
-Presence of family members
-Teach non-pharmacological methods of pain control
-Determine Body Image perception
-Care for patient’s social needs



McKinney, E. S. (Ed.). (2013). Maternal-child nursing (Fourth edition). St. Louis, Missouri: Elsevier/Saunders.
-Ambulate w/out pain
-Afebrile for at least 24 w/out antipyretics
-No S&S of dehydration; fluid & electrolyte hemostasis
-Stable vital signs
-Drainage will be minimal
-Pain is controlled with analgesics
-Bowel sounds and pass at least one stool
-Able to tolerate a soft diet
-No S&S of systematic infection
- Wound is closed w/ no S&S of infection
-Normal CBC

Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: patient-centered collaborative care. St. Louis: Elsevier Saunders.
Desirable Outcomes
You provide discharge teaching to R.O. and her parents. Which of these statements would indicate that more teaching is required?

a. “We need to return if R.O. begins vomiting again or develops a fever.”
b. “R.O. should wait 2 weeks before returning to her gymnastics program.”
c. “We will keep the incision clean and call if we see redness or drainage.”
d. “R.O. can advance her diet to the regular foods that she likes to eat.”
Case Study Outcome

R.O. is discharged to her home with her parents and has an uneventful recovery. She is scheduled for a follow-up visit with the surgeon in 2 weeks
Kaiser, A., Ault, G., Colonge, K., & Moya, E. (n.d.). Post-Discharge Instruction After Major Abdominal Surgery. Keck School of Medicine of USC. Retrieved from http://www.surgery.usc.edu/colorectal/downloads/patientforms/postdischargemajorsurgeryinstructions.pdf

PATHOPHYSIOLOGY
Appendicitis: acute inflammation of the appendix
Most commonly caused by blockege by facecalith (very hard piece of stool)
This phenomenon causes a bacterial infection that invades the wall of the appendix

Other causes: tumors, worms, or other infections.

Results of obstruction:
Restriction in blood flow
Increase internal pressure of the appendix
Pain in epigastric or periumbilical region, and later in RLQ
Nausea, vomiting, low-grade fever and slightly elevated WBC

Complication
Rupture and spread of bacterial matter to peritoneum = peritonitis
S&S of peritonitis: rise in pulse rate, temperature greater than 101 degrees Fahrenheit, increase pain and rigid stomach.

Anyone know how S&S of appendicitis manifest differently in older adults vs young adults?
-Presence of fever or anorexia
-Retrocaecal anatomical position of appendix
-Left-shift leucocytes
-Delay in presentation
In the elderly population:
Sheu, B.-F., Chiu, T.-F., Chen, J.-C., Tung, M.-S., Chang, M.-W., & Young, Y.-R. (2007). Risk Factors Associated with
Perforated Appendicitis in Elderly Patients Presenting with Signs and Symptoms of Acute Appendicitis. ANZ Journal of Surgery, 77(8), 662–666. http://doi.org/10.1111/j.1445-2197.2007.04182.x

* Interesting Note:
Only "5-10% of cases of appendicitis occur in the elderly population", but up to 70% of those result in a rupture
Omari, A. H., Khammash, M. R., Qasaimeh, G. R., Shammari, A. K., Yaseen, M. K. B., &
Hammori, S. K. (2014). Acute appendicitis in the elderly: risk factors for perforation. World Journal of Emergency Surgery, 9(1), 6. http://doi.org/10.1186/1749-7922-9-6

Appendicitis. (n.d.). Retrieved from http://studentnurses3.blogspot.com/p/medical-surgical-nursing-mnemonics.html

Silvestri, L.A. (2014). Gastrointestinal System. Saunders
Comprehensive Review for the NCLEX-RN examination (6th ed., pp. 686). St. Louis, Missouri: Elsevier.
McKinney, E. S. (Ed.). (2013). Maternal-child nursing (Fourth edition). St. Louis, Missouri: Elsevier/Saunders.

Potts, N. L., & Mandleco, B. L. (Eds.). (2012). Pediatric nursing: caring for children and their families (3rd ed). Clifton Park, NY: Delmar Cengage Learning.

Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: patient-centered collaborative care. St. Louis: Elsevier Saunders.

Wilson, B. A., Shannon, M., & Shields, K. (2014). Pearson Nurse’s Drug Guide 2014. Pearson.

Joint Commission FAQ Page | Joint Commission. (n.d.). Retrieved October 23, 2015, from http://www.jointcommission.org/about/jointcommissionfaqs.aspx

Post OP:Incentive Spirometry/ Splinting/ Deep Breathing
Ladwig, G., & Ackley, B. (n.d.). Mosby’s Guide to Nursing Diagnosis (4th ed.). Elsevier.

Ignatavicius, D. D., & Workman, M. L. (2013).
Medical-surgical nursing: patient-centered collaborative care. St. Louis: Elsevier Saunders.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical- surgical nursing: patient-
centered collaborative care. St. Louis: Elsevier Saunders.
Pathology Note:
Necrotic bowel can occur within 24 to 36 hours after peritonitis has occurred and results into adhesions of the bowel
Abscess is an accumulation of pus that results from an infection
Did the R.O.'s hospital stay follow evidence based guidelines?
R.O. is a
12-year-old
girl who lives with her family on a farm in a rural community. R.O. has four
siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were seen
by their primary care provider (PCP) and
diagnosed with viral gastroenteritis
. A week later, R.O. woke
up at 0200 crying and telling her mother that her
stomach “hurts really bad
!” She had an
elevated
temperature of 37.9° C (100.2° F).
R.O. began to
vomit
over the next few hours, so her parents took
her to the local emergency department (ED). R.O.'s
vital signs (VS), complete blood count (CBC), and
complete metabolic panel were normal,
so she was hydrated with IV fluids and discharged to home
with instructions to call their PCP or to return to the ED if she did not improve or worsened. Over the
next 2 days, R.O.'s
abdominal pain localized to the right lower quadrant (RLQ),

she refused to eat
, and
she had
slight diarrhea.
On the third day, she began to have more severe abdominal pain, increased
vomiting, and fever that did not respond to acetaminophen. R.O. returns to the ED. Her VS are 128/78,
130, 28, 39.5° C (103.1° F).
R.O. is guarding her lower abdomen, prefers to lie on her side with her legs
flexed, and is crying.
IV access is established, and morphine sulfate 2 mg IV is administered for pain. An
abdominal CT (computed tomography) confirms a diagnosis of appendicitis. R.O.'s white blood count
(WBC) is
12,000 mm3.
In adhering to QSEN competencies any plan of care must include provisions to satisfy KSAS:

1) Patient Centered Care: Any plan of action regarding RO’s care must be discussed before hand with the patient, incorporating them into the plan of care. Taking RO’s age into consideration; her family must be included in all parts of care within HIPPA’s guidelines. RO’s level of pain and comfort must be continuously assessed to ensure that all measures are being taken to provide optimal comfort. RO reports a pain level of 10/10, which is unacceptable, and a solution must immediately be found. (QSEN Insitute)

2) Teamwork and collaboration: In providing care for pt. RO, effective communication between staff nurses and surgical team to ensure optimal care for RO must take place. Only through effective and age-appropriate communication should be provided. Any complications must be immediately relayed to medical staff to ensure expedite remedy of situations. (QSEN Insitute)

3) Evidence Based Practice: The most up to date evidenced based practice must be utilized when providing care for pt. RO. Such as use of incentive spirometer in order to promote effective breathing pattern following abdominal surgery.(QSEN Insitute)

4) Safety: Safety is of the upmost importance when providing care for pt. RO. Patient’s lung sounds are moist bilaterally. This alerts the nurse of possible respiratory complications. Respiratory status should be assessed continuously while providing care for patient’s latest complications due to complications related to abdominal surgery. Any abdominal palpations must be done gently in order to refrain from disturbing the surgical site. When raising pt. to listen to breathe sounds care must be taken to splint incision site. (QSEN Insitute)

As we progress through the presentation please think:
QSEN Institute. (2014). Pre-Licensure KSAS. Available at: http://qsen.org/competencies/pre-licensure-ksas.
Nursing Note: Discharge


Reason for Admission: Appendicitis

Discharge Diagnosis: Post OP Appendectomy/Abdominal Surgery

Subjective: R.O states “a loss of appetite, fatigue, pain 10/10 and having difficulty taking deep breaths”. Difficulty taking breaths due to the pain. Pain is centralized abdominal.

Objective: 3rd day Post-OP appendectomy; Vital Signs 140/70, 20, 120, 104.4, 93%. NGT is drained increased amount of dark ,greenish black fluid. RO grimacing and guarding abdomen.

Assessment: Lung sounds moist bilaterally, bowel sounds absent and abdomen distended and tender to the touch. Skin: hot, moist and flushed, Strong regular peripheral pulses in all 4 extremities.

Planning: HCP notified, Reassessment determines return to OR

Interventions:
Nursing Interventions: Pt was place in semi-fowlers position. RR, rhythm, O2 monitored. Pain medications and O2 administered. Pt was taught pursed lip breathing and incentive spirometer

Medical interventions: Lysis of adhesions, necrotic bowel removal, drainage of abscesses, post-op wound packing 2x daily and saline irrigation.

Evaluation: RO states decreased pain from 10/10 to 4/10 with pain medication, wound healing progressively, Vital Signs 110/66, 84, 16, 98%, 98.9. Ambulating with limited assistance.

Hospital Course: R.O was admitted on 10/1/15 with progressively worsening abdominal pain, nausea vomiting and fever. She was diagnosed with appendicitis and developed a post op complication of peritonitis on post op day 3. Pain was controlled and patient underwent necrotic bowel removal, adhesion lysis, abscess draining. Abdominal wound was left open and wound packing prescribed 2x daily with normal saline irrigation.

Discharge Instructions: Patient’s family was taught and demonstrated proficiency in wound packing and saline irrigation. Instructed to monitor for signs and symptoms of infection such as fever, redness and warmth at wound site, purulent and/or foul smelling discharge and pain. RO is scheduled to follow up with the surgeon in 2 weeks. Patient’s family given instructions regarding dietary advancement as well as pain management such as medication as well as therapeutic methods.

Missing Information
Assumptions: When R.O. during first admission

Missing info:
-Labs: A blood test
-Diagnostic tools: Chest x-ray & EKG
-Allergic reactions to medication and anesthesia
- How and when the appendix ruptured
- Lack of description of abscess
-Where IV is located
- Amount and color of drainage from the Penrose and NGT
- The route of the Cefotoxamine; therefore is not a correct/complete prescription
-Other prescribed medications
- Pt was not instructed on how to splint the incision in order to complete her pulmonary toileting.
-Pt should also be instructed how to use the incentive spirometer.
-The pain level was not reassessed after the medication administration to see if the 4-6/10 decreased.
-O2 saturation

Legal themes:
Obtaining surgical consent from minor.

The importance of care givers in the patient care, especially in major abdominal surgery will help to facilitate physical, emotional and developmental needs. The parents will be able to notice any signs or symptoms of adverse reactions. They can also assist the patient in ADLs and cleaning of the surgical area. The patient is still a child and will need increased support from the parents. An open abdominal wound for a 12 year old will require help from the parents for the physical healing; and also emotionally since it can lead to disturbed body image.
Ahmed Shahzad
Cheryl Encarnacion
Kavita Jaijairam
Lauren Phillips
Raquel Blanco
Shane Josiah

• Potential for fluid and electrolyte imbalance
• Pain
• Reduced bowel function
• Skin integrity changes
• Anxiety

S: Patient R.O. is post appendectomy day 3 w/ temp of 104.4 F. Lung sounds are moist bilaterally and the NGT has increased drainage with fluid being dark, greenish black. Patient is still NPO.

B: RO underwent appendectomy 3 days ago due to ruptured appendix. RO’s peritoneum was inflamed and abscesses were observed near the colon and small intestine. Patient was admitted to the surgical unit with NPO status in preparation for procedure, she also had a NGT, foley catheter, IV, abdominal dressing and a Penrose drain.

A: My assessment of the situation is that patient is currently experiencing complications related to appendectomy.

R: I recommend that you see the patient as soon as possible to assess need for further surgical intervention.

Contributers:
QSEN Competencies
Assess patient’s bowel sounds and presence of flatulence. If BM occurs, record time and character. Contact surgeon if BM occurs.
Monitor wound incision and drainage. Also abdominal distention.
Assess level of pain (intensity & duration) and administer medication, perform non-pharmacological pain management techniques.
Turn and position patient q2h.
Assess vital signs, I/O’s, and weight.
Raise HOB to 45 degrees and assess patient’s respiration rate and lung sounds. O2 sat monitoring.
https://jeopardylabs.com/play/appendicitis2
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