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PEDS Concept

Map

Risk for deficient fluid volume

Risk factors: factors influencing fluid needs, loss of fluid through abnormal routes, deviations affecting intake of fluids

AEB NPO status, verbalization of N/V for 5 days, and increased urine concentration & straw-color

Goals

Evaluation

STO #1

Pt will maintain normal blood pressure and pulse throughout the shift

1. Goal partially met: pt blood pressure and pulse slightly elevated, but could be due to pain

Interventions

STO #2

Pt will maintain urine output of >30mL/hour throughout the shift

Patient Snapshot

Nursing

Diagnosis

2. Goal met: pt had 300mL output in 4.5 hours

1. Nurse will maintain IV fluid administration and frequent V.S. (every 4 hours at a minimum)

  • Glucose supplement in IV solution increase fluid absorption and sugar levels for metabolic needs; replaces intravascular volume (Kong, Aldous, Handley, & Clarke, 2013)

By Mariah McGriff

References

3. Unable to assess: did not see pt after shift

LTO #1

Pt will maintain urine output >30mL/hr, normal blood pressure & pulse, and moist mucous membranes throughout hospital stay

Norther Arizona University

Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care. Maryland Heights, MO: Mosby.

Deglin, J.H., Vallerand, A., & Sanoski, C. (2014). Davis's drug guide for nurses (14th Ed.). Philadelphia: F. A. Davis Company.

Kong, V., Aldous, C., Handley, J., & Clarke, D. (2013). The cost effectiveness of early managements of acute appendicitis underlies the importance of curative surgical services to a primary healthcare program. Annals of the Royal College of Surgeons of England, 95(4), 280-4.

London, M.L., Ladewig, P.W., Davidson, M.R., Ball, J., Bindler, R.M., & Cowen, K.J. (2017). Maternal & child nursing care. Boston: Pearson Education, Inc.

Porth, C.M. (2014). Essentials of pathophysiology: concepts of altered states. Philadelphia: Wolters Kluwer.

Thompson, Schuh, Gravel, Reid, Fitzpatrick, Turner, & Nettel-Aguirre. (2015). Variation in the diagnosis and management of appendicitis at canadian pediatric hospitals. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 22(7), 811-22.

Yu, Abbas, Smith, Carberry, Ren, Patel, & Lopez. (2017). Time-driven activity-based costing: a dynamic value assessment model in pediatric appendicitis. Journal of Pediatric Surgery, 52(6), 1045-1049.

2. Nurse will teach pt and mother the importance of urinating in the urinal and keeping it for the nurse to assess.

  • Urine output is critical in operative pt's and assessing renal damage and/or hypovolemia (Ackley & Ladwig, 2010)

3. Nurse will assess for signs of hypovolemia (cold clammy skin, weak thready pulse, oliguria)

  • These signs present with a shift in fluid from interstitial space to extracellular fluid (Ackley & Ladwig, 2010)
  • C.H.
  • Full Code
  • Hispanic Male
  • 15 years old
  • Allergies: NKA
  • Diet: NPO
  • Activity: bed rest
  • Language: Spanish only
  • Mom at bedside: no visitors allowed per report
  • Mom in merge program to leave abusive relationship
  • BMI: 30 (wt-106kg; ht-6'2'')

Pathophysiology

Appendicitis w/perforation

Acute pain r/t biological injury agents AEB pt. statement of 9 on pain scale, pt inability to ambulate, guarding of abdomen, and diaphoresis

Primary Diagnosis

  • Appendicitis w/perforation

Impaired verbal communication r/t language and cultural differences AEB "no habla ingles," and patient and patient shaking their head "no."

Interventions

Evaluation

Goals

History:

1. Nurse will ask pt to ID comfort pain level (from 0-10) to set a basis for pain management effectiveness at the beginning of shift.

  • focus on individualized pain management plans to decrease cardiopulmonary and thromboembolic complications (Ackley & Ladwig, 2010)

1. Goal met: pt verbalized comfort pain level of 5/10 considering circumstances

STO #1

Pt will establish a comfort-functional goal by verbalizing pain tolerance # on pain scale by 0900

Interventions

2. Goal partially met: pt pain level decreased, but not to comfort level by the time he left to surgery (pain can be difficult to decrease with his condition pre-op)

LTO #1

Pt will perform ambulation activities twice per day by discharge

2. Nurse will administer IV opioid analgesic every 3 hours when needed.

  • indicated for TX of mod-sever pain (Yu et al., 2017)

1. Nurse will use the Rosetta Stone system for communication with pt and mother

  • Using professional and medical interpreters are a legal responsibility of the staff (Ackley & Ladwig, 2010)

Goals

STO #2

Pt will report pain management by achieving manageable pain # on pain scale within the next 2 hours

Evaluation

3. Unable to assess: pt not discharged or able to ambulate at time

STO #1

Pt will use an alternative and effective method of communication (a translator).

2. Nurse will have Rosetta Stone system ready and available when the surgical team comes for information and consent

  • Language barriers are associated with longer hospital stays, less understanding of physician/surgeon's explanations, and less pt satisfaction (Ackley & Ladwig, 2010)

3. Nurse will teach pt about nonpharmacological methods (distraction, relaxation, splinting) when preparing for ambulation

  • Used to supplement pharmacological interventions post-op (London et al., 2017)

1. Goal met: pt and mother used Rosetta Stone to communicate with nurse

Acute appendicitis is one of the most common ED admissions in the pediatric population. Even though the etiology is mostly unknown, dehydration and/or viral infections can be related to the submucosal lymphoid hyperplasia that obstructs the appendix. The obstruction then causes bacteria to be trapped within the appendix and leads to a multitude of additional problems. An inflammation response and/or distention is correlated to a decrease in venous drainage, congestion, and ischemia of the appendix. When the obstructed appendix is left untreated, necrosis can occur and perforation can ultimately result (usually over 72 hours). In addition, the appendix has innervation from T10 that causes periumbilical pain. The exudate released by the inflammation can also cause more intense pain if it comes in contact witht he parietal peritoneum. As perforation occurs, more inflammation and bacteria leads to peritonitis. (Porth, 2014)

STO #2

Pt and mother will demonstrate understanding of pre-operative procedures and sign the surgical consent.

2. Goal met: pt and mother demonstrated and verbalized understanding; mother signed consent

  • Brother jumped on him 10/22
  • TMC ED with N/V and right testicular pain
  • Sent home with Zofran
  • 10/26 TMC ED with unrelieved N/V, right testicular pain, and RLQ pain
  • Transferred to Diamond Childrens BUMC by ambulance

3. Nurse will communicate with the pt and mother that they should always ask for a translator and that the Rosetta Stone is available throughout the hospital

  • It is a legal responsibility for health care workers to provide language access services for pt's to understand care (Thompson et al., 2015)

LTO #1

Pt and mother will understand all care throughout hospital stay by effective communication with translator.

3. Not able to assess: was not on shift or see pt and mother rest of hospital stay

Medications

Morphine 6mg/3mL IV push Q3hr PRN for pain >4

Class: Opioid analgesic

Indication: Severe pain

Action: Bind to opiate receptors to alter perception of pain stimuli

Side Effects: Confusion, sedation, respiratory depression, constipation, hypotension

Effectiveness: Partially effective- given 10/27 @ 0852 for pain of 9/10 and decreased to 7/10 @ 0926

Interventions/Teaching: Push over 5 min; assess pain, V.S., LOC

Lab/Test Results

Assessment Findings

Ondansetron 4mg/2mL IV push Q6hr for N/V

Class: Antiemetic

Indication: Prevention of N/V

Action: Blocks serotonin receptors in vagal nerve

Side Effects: HA, constipation, diarrhea

Effectiveness: Partially effective- given 10/27 @ 0846 (patient holding bucket) and was able to set bucket down @0926; verbally said had decreased some

Interventions/Teaching: Assess V.S., N/V, bowel sounds, abdominal distention; push over 5 min before morphine since it can also cause N/V

Focused Assessment

Intake & Output

From 10/27 0700- 10/27 1130 (taken to surgery)

Acetaminophen 650mg PO PRN Q4hr for pain (1-3) or temperature (>38.3 C)

Class: Nonopioid analgesic & antipyretic

Indication: Mild-moderate pain or fever

Action: Inhibit prostaglandins that are mediators of pain and fever

Side Effects: Muscle spasms, constipation, atelectasis, agitation, HA

Effectiveness: Effective: given 10/27 0413 for temp of 39C; decreased to 38.1 @ 0700

Interventions/Teaching: Assess for rash, pain, and temperature change;

Intake 905 mL

  • Oral Fluids: 0mL (NPO)
  • IV Fluid: 905 mL
  • Respiratory: clear, no wheezes, no crackles
  • Cardiovascular: regular/strong radial pulse w/ apical pulse, regular/strong pedal pulses, sinus tachycardia
  • Neurological: alert and oriented x4
  • Gastrointestinal: hypoactive bowel sounds in all 4 quadrants; RLQ tenderness (sharp, intermittent); N/V
  • Integumentary: warm, intact, diaphoretic skin
  • Peripheral 22g IV in right AC
  • Blood return assessed
  • Continuous infusion running

Output 300mL

  • Urine
  • 0700 150mL
  • 0840 50 mL
  • 1115 100mL

Zosyn 3.375g IV in 100 mL D5 with LR (given once at 0600 per surgeon request for possible adjustment after surgery)

Class: anti-infective extended spectrum penicillin

Indication: Prophylactic for appendicitis and suspected appendectomy w/rupture

Action: bind to bacterial cell wall to cause cell death and inhibit beta-lactamase to prevent destruction of penicillin component

Side Effects: Seizure, diarrhea, pain/plebitis @ IV site, Cdif, anaphylaxis

Effectiveness: Unable to assess- did not see the patient after surgery

Interventions/Teaching: Assess IV site, V.S., sign of anaphylaxis, skin rashes,

Continuous infusion of D5 in LR 200mL/hr

Class: Glucose/mineral/electrolyte supplement

Indication: Vascular and intracellular hydration maintenance pre-operative

Action: Maintain water distribution, acid-base balance, & osmotic pressure by stabilizing permeability of cell walls

Side Effects: Pulmonary edema, hyperglycemia

Effectiveness: Unable to assess- only one set of labs- nothing to compare (could be done post-op)

Interventions/Teaching: Daily wt, I&O's, edema, lung sounds, assess IV site

Vital Signs

  • 10/27 @ 0840
  • Temp: 37.4 C
  • RR: 26
  • BP: 130/78
  • HR: 114
  • Pain: 9/10
  • O2 Sat: 96%
  • 10/27 @ 1136
  • Temp: 37.8 C
  • RR: 24
  • BP: 132/83
  • HR: 109
  • Pain: 8/10
  • O2 Sat: 94%
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